Show 91 older citations
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Plan reviewed/updated annually 55 Pa. Code §3270.27(b)
2nd Citation: Same citation Previously cited on 1.7.25. There was no documentation that the Emergency Plan had been reviewed/updated since 1.24.23, which did not meet the annual requirement. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The updated Emergency Plan dates were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Training regarding plan/Exp, educ., training at facility 55 Pa. Code §3270.27(c)/3270.192(2)(iii)
2nd Citation: Same citation previously cited on 1.7.25. The file for Staff #1 did not contain documentation of Emergency Plan training by 1.4.24 or 1.4.25. The file for Staff #2 did not contain documentation of Emergency Plan training by 1.23.24. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The updated Emergency Plan training dates were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Letter to parents 55 Pa. Code §3270.27(e)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation that the operator provided to parents of enrolled children, a letter explaining the emergency procedures. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The updated Parent Letter was provided to the CR on 3.6.25”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(6)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation that an Emergency Drill had been conducted. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Emergency Drill Log was provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Every 60 days 55 Pa. Code §3270.94(a)(1)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation of Fire Drills being conducted. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Fire Drill Log was provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(f)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation that a copy of the Emergency Plan and updates were provided to the local municipality and county emergency management agency. The Provider's submitted correction date was 1.21.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The dates of the updated Emergency Plan, which were sent to the local municipality and county, were provided to the CR on 3.6.25”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Transportation
Pick-up and drop-off points 55 Pa. Code §3270.171(a)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation that the operator notified local traffic safety authorities, in writing, of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Annual Traffic Letter was provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Records & paperwork
On file at facility 55 Pa. Code §3270.18(a)
2nd Citation: Same citation previously cited on 1.7.25. There was no documentation of current Liability Insurance, as the one produced was dated 6.11.22 to 6.11.23. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Liability Insurance document was provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Training & qualifications
Fire safety - 1 yr./Exp, educ., training at facility 55 Pa. Code §3270.31(e)(4)(ii)/3270.192(2)(iii)
2nd Citation: Same citation previously cited on 1.7.25. The file for Staff #1 did not contain documentation of Fire Safety training in 2023. The file for Staff #2 did not contain documentation of Fire Safety training in 2024. The Provider's correction date was 1.21.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Fire Safety training dates were provided to the CR on 3.6.25”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Training & qualifications
Staff evaluations 55 Pa. Code §3270.34(a)(6)
2nd Citation: Same citation previously cited on 1.7.25. The file for Staff #1 did not contain documentation of a written evaluation in by 1.5.24 or 1.5.25. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The written evaluations were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Records & paperwork
Designated release persons 55 Pa. Code §3270.123(a)(5)
2nd Citation: Same citation previously cited on 1.7.25. The Agreement, in the files for Child #1, Child #4, and Child #5 did not contain the release person(s) specified by the parent. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Child file documents were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Records & paperwork
Name/address/phone release person 55 Pa. Code §3270.124(b)(7)
2nd Citation: Same citation previously cited on 1.7.25. The Emergency Contact form, in the files for Child #2 and Child #4, did not contain the release person's phone number. The Emergency Contact form, in the file for Child #5, did not contain the release person's address. The Provider's submitted correction date was 1.28.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The Child File documents were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Records & paperwork
Updated every 6 months/Emergency info/agreement updated 6 mos 55 Pa. Code §3270.124(f)/3270.181(c)
2nd Citation: Same citation previously cited on 1.7.25. The Emergency Contact form and the Agreement did not contain documentation that the parent reviewed and/or updated the forms at least once in a 6-month period. Provider's submitted correction date was 1.28.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The dates of the reviewed Emergency Contact form and Agreement were provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Follow-up
Mar 6, 2025
Inspection
Records & paperwork
Availability of certificate of compliance and applicable regulations 55 Pa. Code §3270.25(a)
2nd Citation: Same citation previously cited on 1.7.25. The current Certificate of Compliance was not available, as the one on-file was dated 3.7.23 to 3.7.24. There was no documentation that the operator provided the parent of enrolled children with information on how to access the regulations electronically or with instructions for contacting the regional child care office. The Provider's submitted correction date was 1.20.25, which was exceeded.
Center’s plan of correction (implemented, Mar 10, 2025): “The current Certificate of Compliance was provided to the CR on 3.6.25.”
Re-cited at a follow-up visit; counted once, with the original citation.
Comply with CPSL 55 Pa. Code §3270.32(a)
The file for Staff #1 contained documentation of a State Police Clearance dated 1.2.20, which has expired, and a new State Police Clearance was not in the file. The file for Staff #1 contained documentation of Mandated Reporter training on 1.1.20, which has expired, and documentation of a new Mandated Reporter training was not in the file.
Center’s plan of correction (not implemented, Mar 5, 2025): “Staff 1 actually had/ has current and multiple verifications of State Police Clearances. (1/02/2020, 12/05/2023, and she even redid it as os 1/28/2025) All 3 clearances will stay on file for verification. There are 2 binders one floral and one that's white. It has current information for center and…”
Inspection status on COMPASS: Non Compliant – Finalized
Comply with CPSL/CPSL information 55 Pa. Code §3270.32(a)/3270.192(4)
The file for Staff #2 (see IS Code Sheet) contained a Disclosure Statement dated 12.1.23, which was signed after the first date of caring for children.
Center’s plan of correction (not implemented, Mar 5, 2025): “Staff 2 signed the incorrect year/ date on disclosure. Our disclosure statements are done annually in accordance to the State of Pennsylvania.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Plan reviewed/updated annually 55 Pa. Code §3270.27(b)
There was no documentation that the Emergency Plan had been reviewed/updated since 1.24.23, which did not meet the annual requirement.
Center’s plan of correction (not implemented, Mar 5, 2025): “The annual update for the emergency plan was and is updated yearly my last inspection had documentation of it. Owner had the 2024 documentation in the other folder. There are 2 binders one floral and one that's white. It has current information for center and the other has prior year since we have…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Training regarding plan/Exp, educ., training at facility 55 Pa. Code §3270.27(c)/3270.192(2)(iii)
The file for Staff #1 did not contain documentation of Emergency Plan training by 1.4.24 or 1.4.25. The file for Staff #2 did not contain documentation of Emergency Plan training by 1.23.24.
Center’s plan of correction (not implemented, Mar 5, 2025): “Staff 1 and Staff 2 had emergency plan training and they were both signed, the same strips of paper that are signed for the acknowledgment were at the bottom of the file bin.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Letter to parents 55 Pa. Code §3270.27(e)
There was no documentation that the operator provided to parents of enrolled children, a letter explaining the emergency procedures.
Center’s plan of correction (not implemented, Mar 5, 2025): “The emergency letter for parents is posted in our parent information folder that doubles as our "board" it shows local police, hospital information etc. Owner has put information in updated parents guide. This has been corrected so it's in 2 areas now.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(6)
There was no documentation that an Emergency Drill had been conducted.
Center’s plan of correction (not implemented, Mar 5, 2025): “The current year Fire Drills (every 60 days) and annual Emergency Drill log are current and up to date. They were in the other binder. There are 2 binders one floral and one that's white. It has current information for center and the other has prior year since we have to keep information for a…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Every 60 days 55 Pa. Code §3270.94(a)(1)
There was no documentation of Fire Drills being conducted.
Center’s plan of correction (not implemented, Mar 5, 2025): “The current year Fire Drills (every 60 days) and annual Emergency Drill log are current and up to date. The last Fire drill was conducted in cafe by staff 1 and staff 2 with 10 kids present on 1/17/25. Fire Drills/ Annual Emergency Drills were in the other binder. There are 2 binders one floral and…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(f)
There was no documentation that a copy of the Emergency Plan and updates were provided to the local municipality and county emergency management agency.
Center’s plan of correction (not implemented, Mar 5, 2025): “Updated emergency plans were sent to local and county officials (Moon Township and Pittsburgh Police) the Moon update was done as of 1/21/25 because in 2024 I did it to do a POC, I emailed notice to Moon Police with prior year inspector CCed on the email. (local and county)”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Transportation
Pick-up and drop-off points 55 Pa. Code §3270.171(a)
There was no documentation that the operator notified local traffic safety authorities, in writing, of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.
Center’s plan of correction (not implemented, Mar 5, 2025): “The annual update for the emergency plan was and is updated yearly my last inspection had documentation of it. Moon Police was notified. Owner had the 2024 documentation in the other folder. There are 2 binders one floral and one that's white. It has current information for center and the other has…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Records & paperwork
On file at facility 55 Pa. Code §3270.18(a)
There was no documentation of current Liability Insurance, as the one produced was dated 6.11.22 to 6.11.23.
Center’s plan of correction (not implemented, Mar 5, 2025): “Owner has and had current liability insurance, the updated policy was in the other binder (there are 2 binders one floral and one that's white. It has current information for center and the other has prior year since we have to keep information for a certain time period) Owner believed that…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Training & qualifications
Fire safety - 1 yr./Exp, educ., training at facility 55 Pa. Code §3270.31(e)(4)(ii)/3270.192(2)(iii)
The file for Staff #1 did not contain documentation of Fire Safety training in 2023. The file for Staff #2 did not contain documentation of Fire Safety training in 2024.
Center’s plan of correction (not implemented, Mar 5, 2025): “Staff 1 and Staff 2 have Fire Training for both 2023/2024 that can be verified per PD registry. Once you complete the training now certificate doesn't print out. You have to screenshot the page to show the pass in the one credit.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Training & qualifications
Staff evaluations 55 Pa. Code §3270.34(a)(6)
The file for Staff #1 did not contain documentation of a written evaluation in by 1.5.24 or 1.5.25.
Center’s plan of correction (not implemented, Mar 5, 2025): “Staff 1 had 2023 staff evaluation in their folder that was dated and done by prior Director Victoria Deakings, 1/5/2023, new and current Director Dhana King did 2024 1/30/2024 and did a new one on 12/30/2024 to carry through to 12/30/25. Owner had missing evaluations in the other binder. There are…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Records & paperwork
Designated release persons 55 Pa. Code §3270.123(a)(5)
The Agreement, in the files for Child #1, Child #4, and Child #5 did not contain the release person(s) specified by the parent.
Center’s plan of correction (not implemented, Mar 5, 2025): “The owner has the discussed with staff to thoroughly go over student enrollment documents to ensure that all necessary spots are filled out and properly dated. All emergency contacts/release persons have been correctly added as of 1/28/ 2025 for child 1, 4, and 5.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Records & paperwork
Name/address/phone release person 55 Pa. Code §3270.124(b)(7)
The Emergency Contact form, in the files for Child #2 and Child #4, did not contain the release person's phone number. The Emergency Contact form, in the file for Child #5, did not contain the release person's address.
Center’s plan of correction (not implemented, Mar 5, 2025): “Child 2 and 4 forms have been updated with release persons phone number. The owner has the discussed with staff to thoroughly go over student enrollment documents to ensure that all necessary spots are filled out and properly dated. All emergency contacts have been correctly updated as of 1/28/…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Records & paperwork
Updated every 6 months/Emergency info/agreement updated 6 mos 55 Pa. Code §3270.124(f)/3270.181(c)
The Emergency Contact form and the Agreement did not contain documentation that the parent reviewed and/or updated the forms at least once in a 6-month period.
Center’s plan of correction (not implemented, Mar 5, 2025): “The owner has the discussed with staff to thoroughly go over student enrollment documents to ensure that all necessary spots are filled out and properly dated. All 6 month reviews have been correctly added as of 1/28/ 2025 for all children.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 31, 2024
Inspection
Records & paperwork
Availability of certificate of compliance and applicable regulations 55 Pa. Code §3270.25(a)
The current Certificate of Compliance was not available, as the one on-file was dated 3.7.23 to 3.7.24. There was no documentation that the operator provided the parent of enrolled children with information on how to access the regulations electronically or with instructions for contacting the regional child care office.
Center’s plan of correction (not implemented, Mar 5, 2025): “The current Certificate of Compliance was printed and in the other binder. There are 2 binders one floral and one that's white. It has current information for center and the other has prior year since we have to keep information for a certain time period) Owner believed that separating them would…”
Inspection status on COMPASS: Non Compliant – Finalized
Comply with CPSL/CPSL information 55 Pa. Code §3270.32(a)/3270.192(4)
The file for staff person #2 lacked documentation of current PA Child Abuse clearance results. This is evidenced by the previously documented PA Child Abuse clearance results on file have an expiration date of 8/17/23.
Center’s plan of correction (implemented, Dec 26, 2023): “Staff person 2 renewed incorrect clearance and had double on file of FBI, as of 12/7/2023 PA Child Abuse clearance is on file and up to date.”
Citation
Dec 6, 2023
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(6)
The facility has not conducted an emergency drill within the last 12 months. The most recent documentation on file is dated 6/8/22.
Center’s plan of correction (implemented, Dec 26, 2023): “Site has done a emergency drill since 6/8/22, the log sheet wasn't in the folder when inspector was on site. It was misplaced and now on file and up to date as of 12/15/2023. The last emergency drill was done on 10/31/2023.”
Citation
Dec 6, 2023
Inspection
Emergency preparedness
Every 60 days 55 Pa. Code §3270.94(a)(1)
The facility did not have documentation of conducting a fire drill within the last 60 days. The most recent documentation on file is dated 4/11/23.
Center’s plan of correction (implemented, Dec 26, 2023): “Site has done a fire drill since 4/11/23, the log sheet wasn't in the folder when inspector was on site. Sheet is now on file and up to date. The last fire drill was done on 11/29/2023. Owner was completing every 30 days and reread regulation with inspector that they need done at least once every…”
Citation
Dec 6, 2023
Inspection
Records & paperwork
On file at facility 55 Pa. Code §3270.18(a)
The legal entity did not have a copy of the insurance policy on file at the facility. The most current copy of liability insurance on file was observed to be dated 6/11/22 to 6/11/23.
Center’s plan of correction (implemented, Dec 26, 2023): “As of 12/19/2023 new statement is on file and up to date on site in information binder. Making sure that site has adequate copy of up to date insurance information on file and keeping up to date with the dates on documents to prevent old information to be on file. Owner has set electronic google…”
Citation
Dec 6, 2023
Inspection
Training & qualifications
Health and Safety Training 55 Pa. Code §3270.31(f)
Staff person #1 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety. The Health and Safety training on file is dated 6/1/23.
Center’s plan of correction (implemented, Dec 26, 2023): “Staff person 1 had a unexpected surgery and came back after window. As of 6/1/2023, training was complete, verified and on file by owner.”
Citation
Dec 6, 2023
Inspection
Records & paperwork
Designated release persons 55 Pa. Code §3270.123(a)(5)
The agreement on file for child #1 did not specify the persons designated by the parent to whom the child may be released.
Center’s plan of correction (implemented, Dec 26, 2023): “Child 1 file was updated with proper emergency contact information and reverified by owner and parent. This was completed on 12/15/2023.”
Citation
Dec 6, 2023
Inspection
Records & paperwork
Insurance coverage information 55 Pa. Code §3270.124(b)(6)
The emergency contact form on file for child #1 did not include information on the health insurance coverage and policy number for the child.
Center’s plan of correction (implemented, Dec 26, 2023): “Owner updated child 1s file with insurance and doctor information the same day inspector came after parent produce proper information.”
Citation
Dec 6, 2023
Inspection
Records & paperwork
Name/address/phone release person 55 Pa. Code §3270.124(b)(7)
The emergency contact form on file for child #2 did not include the telephone numbers of the individuals designated by the parent to whom the child may be released.
Center’s plan of correction (implemented, Dec 26, 2023): “As of 12/15/23. Owner updated Child #2 file with emergency contact telephone numbers, name, and address.”
Citation
Dec 6, 2023
Inspection
Records & paperwork
Availability of certificate of compliance and applicable regulations 55 Pa. Code §3270.25(a)
The most current certificate of compliance was not posted in a conspicuous location used by parents. The certificate of compliance that was observed to be posted was dated 3/11/22 to 3/11/23.
Center’s plan of correction (implemented, Dec 26, 2023): “Certificate of Compliance is now on file and updated as of 12/15/23.”
Follow-up
Feb 1, 2023
Inspection
Other standards
30 or fewer hours a week, director or director/GS present at least 20% of operational hours. 55 Pa. Code §3270.241(c)(1)(i)
*SECOND VIOLATION The director has not been present at the facility at least 20% of the program's operational hours each week. Previously cited on SIN-00216466 on 12/19/22.
Center’s plan of correction (implemented, Feb 16, 2023): “I have hired a new director that will be present 20-40% of the time weekly.”
Re-cited at a follow-up visit; counted once, with the original citation.
Pertinent Laws & Regulations/General Health and Safety 55 Pa. Code §3270.14/3270.21
Staff person #1 has been caring for children unsupervised. Staff person #1 has not completed the following pre-service training required prior to caring for children unsupervised: Pennsylvania Health and Safety Update 2022. Staff person #4 has been caring for children unsupervised. Staff person #4 has not completed the following pre-service training required prior to caring for children unsupervised: Pediatric first aid/CPR from a PQAS approved trainer.
Center’s plan of correction (implemented, Jan 20, 2023): “Staff #1 has completed health and safety update as of 1/5/23 and its on file. Staff #4 has been removed from site until further notice and all trainings are complete.”
Inspection status on COMPASS: Non Compliant – Finalized
Comply with CPSL/CPSL information 55 Pa. Code §3270.32(a)/3270.192(4)
The file for staff person #2 lacked documentation of child abuse clearance results prior to date of hire (See LIS CODE SHEET) required for provisional hiring under CPSL. The file for staff person #2 lacked application of a NSOR clearance prior to date of hire (See IS CODE SHEET) required for provisional hiring under the CPSL. Staff person #2 cannot work in the facility until the NSOR and Child Abuse clearance results are submitted and verified.
Center’s plan of correction (implemented, Jan 20, 2023): “staff #2 has submitted their nsor and child abuse clearances which are printed and on file as of 1/6/23.”
Inspection status on COMPASS: Non Compliant – Finalized
Two facility persons present in facility 55 Pa. Code §3270.54(a)
Staff person #1 was observed to be caring for six children alone and there was not a second facility person present.
Center’s plan of correction (implemented, Jan 27, 2023): “Staff #1 is aware that they must have another staff present or a building facility personnel present at all times. Staff 4 was removed as the facility person until their file is updated and corrected. Staff #1 #2 and #3 are alternating shifts until this is corrected to have 2 persons present at all…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Emergency preparedness
Contact when arises 55 Pa. Code §3270.27(a)(3)
The facility's emergency plan lacked a method for facility persons to contact parents when an emergency situation arises.
Center’s plan of correction (implemented, Jan 27, 2023): “Emergency Plan was updated, printed, and filed in parent binder as of 1/7/23. The update included ways of mass text, email, and verbal calls (once we are safe etc) to notify parents of a emergency situation.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Emergency preparedness
Plan reviewed/updated annually 55 Pa. Code §3270.27(b)
The operator lacked reviewing the emergency plan annually. The most current emergency plan on file was observed to be dated 5/1/21.
Center’s plan of correction (implemented, Jan 27, 2023): “Plan was updated in 2022 and of course the new updates that were just applied, however I failed to change the date in 2022 when it was updated. The new updated plan is appropriately dated for changes effective 12/20/22 and on file.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Health & medication
12 months prior to service and every 24 months thereafter/Health assessment, TB test 55 Pa. Code §3270.151(a)/3270.192(3)
The file for staff person #3 was observed not to contain documentation of a health assessment being completed within 12 months prior to date of hire (See LIS CODE SHEET). The health assessment on file for staff person #3 was observed to be dated 9/1/22.
Center’s plan of correction (implemented, Jan 27, 2023): “Staff #3 has health assessment dated 9/22/2020 operator only gave the updated copy by mistake and not the last 2 but staff #3 has all 4 of her prior health assessments on file.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Health & medication
Mantoux TB 55 Pa. Code §3270.151(c)(2)
The file for staff person #3 lacked documentation of a tuberculosis screening at initial employment. (See LIS CODE SHEET). The TB test on file for staff person #3 was observed to be dated 9/8/22.
Center’s plan of correction (implemented, Jan 27, 2023): “Operator failed to understand that even though staff #3 is in a childcare facility setting, other than ours and had a up to date health assessment that staff #3 needed a up to date tb test as well for initial assessment. Staff #3 provided documentation of previous health forms and Tb tests.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Emergency preparedness
Written record 55 Pa. Code §3270.94(a)(9)
There was no fire drill log on file at the facility available for review at the time of inspection.
Center’s plan of correction (implemented, Jan 20, 2023): “Fire Drill and emergency drill log are on site and located in folder that has annual fire alarm test as well.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(1)
The facility's emergency plan lacked accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the faculty's premises.
Center’s plan of correction (implemented, Jan 24, 2023): “Emergency plan was updated with all accommodations as of 12/20/22 its on file in information binder.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(2)
The facility's emergency plan lacked accommodations for evacuation of children from the facility building and evacuation of children to a location away from the facility premises.
Center’s plan of correction (implemented, Jan 27, 2023): “emergency plan was updated and filed in information binder that is on site.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Health & medication
Health information/Initial and subsequent health reports 55 Pa. Code §3270.131(a)/3270.182(1)
The file for child #3 lacked an initial health report within 60 days following the first day of attendance at the facility. The file for child #4 lacked an initial health report within 60 days following the first day of attendance at the facility. The health report on file for child #4 was observed to be dated 12/1/22.
Center’s plan of correction (implemented, Jan 24, 2023): “Child #3s parent was having a hard time getting health assessment done due to Covid restrictions, operated was still under the influence that there was extended time to provide health assessment. Child #3 is removed from the program until a health report is submitted. Child #4 has a health form in…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Transportation
Pick-up and drop-off points 55 Pa. Code §3270.171(a)
The facility lacked written documentation of notifying the local traffic safety authorities of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.
Center’s plan of correction (implemented, Jan 25, 2023): “Notification is on file now in the information binder also.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Pertinent Laws & Regulations/General Health and Safety 55 Pa. Code §3270.14/3270.21
The emergency plan for the facility did not include 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). The facility lacked policies regarding recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with crying, fussing, or distraught children, and prevention and identification of child maltreatment.
Center’s plan of correction (implemented, Jan 27, 2023): “Emergency Plan was updated as of 12/20/2022 with the continuity plan and Maltreatment policy which addresses shaken baby syndrome and abusive head trauma. Also, in the continuity plan electronic file keeping for employees and students was discussed via Procare, City Span, and Google Drive. Which…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Training & qualifications
Fire safety - 1 yr. 55 Pa. Code §3270.31(e)(4)(ii)
The two most recent fire safety trainings on file for staff person #1 was observed to be dated more than one year apart: 12/29/19 and 12/28/22.
Center’s plan of correction (implemented, Jan 25, 2023): “Staff #1 was stressed the importance of staying on top of trainings and certifications. However, there is a training that was completed 8/4/2021 which would take staff #1 until 8/4/22 that was in PD registry but not printed. Staff #1 also took a online certification during 2020 covid time which was…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Training & qualifications
Health and Safety Training 55 Pa. Code §3270.31(f)
Staff person #3 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.
Center’s plan of correction (implemented, Jan 20, 2023): “staff #3 retook cpr first aid on 11/06/22 and it is on file.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Signed 55 Pa. Code §3270.123(a)
The file for child #4 lacked an agreement form and was not signed by the operator and the parent.
Center’s plan of correction (implemented, Jan 27, 2023): “Agreement is on for child #4 is onfile and wasn't accessible during the initial inspection, due to the cabinet being locked. To prevent that from happening operator and director, will be keeping an additional set of keys with school staff and another set on cabinet in toy bin for access if…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Parent home/work address, phone 55 Pa. Code §3270.124(b)(3)
The emergency form on file for child #5 lacked the enrolling parent's work telephone number.
Center’s plan of correction (implemented, Jan 27, 2023): “Operator missed lack of work telephone number, operator submitted emergency contact to parent again and parent advised that working in a medical setting she cannot be directly accessed through work phone and specified that cell phone is the direct contact for her at work. Parent initialed and…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Written consent/Consent for emergency medical care required prior to admission 55 Pa. Code §3270.124(b)(4)/3270.182(3)
The emergency form on file for child #1 lacked written consent signed by a parent for emergency medical care which is required prior to admission.
Center’s plan of correction (implemented, Jan 27, 2023): “Operator glanced at the emergency contact for child #1 and assumed that the writing was a signature due to the scribble on each line, the parent actually wrote yes as authorization instead of signing. I went to parent of child #1 and explained we needed a full signurture for authorization. Parent…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Name/address/phone release person 55 Pa. Code §3270.124(b)(7)
The emergency form on file for child #2 and #3 lacked the address of the individuals designated by the parent to whom the child may be released.
Center’s plan of correction (implemented, Jan 27, 2023): “Operator assumed child #2 mom's note of above persons for pick up was ok due to the information above and contacts fully having names, telephone numbers, and addresses filled out correctly. Operator reached out to child #2 and #3 parents to correctly fill out and finish form which was effective and…”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Each child 55 Pa. Code §3270.181(a)
The provider was unable to access individual records for each child enrolled in the facility.
Center’s plan of correction (implemented, Jan 27, 2023): “As previously mentioned, the cabinet was locked, to rectify that situation from happening again operator has placed extra keys on top of cabinet in toy bin as well as leaving a pair in the main office.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Consent for administration of minor first-aid required prior to admission 55 Pa. Code §3270.182(5)
The emergency form on file for child #1 lacked written consent signed by a parent for administration of minor first-aid procedures by facility staff, which is required prior to admission.
Center’s plan of correction (implemented, Jan 27, 2023): “As previously mentioned, child #1s mother wrote yes in place of signatures for which she did write all yes for first aid etc this has been corrected, signed, and updated in file.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Individual Records 55 Pa. Code §3270.191
An individual record for staff persons #1, #2, #3 and #4 were observed not to be on site and the provider was not able to access them at the time of the inspection.
Center’s plan of correction (implemented, Jan 27, 2023): “As previously mentioned, the cabinet with all staff and students' files were locked and no key was present, operator now has 2 extra sets of keys on site on top of the cabinet in the toy bin and in the main office.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Records & paperwork
Two written references 55 Pa. Code §3270.192(5)
The file for staff person #2 was observed to lack two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.
Center’s plan of correction (implemented, Jan 20, 2023): “Operator failed to place references in file on staff #2(they were in google drive) and operator printed references and place them on file for staff #2”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Other standards
30 or fewer hours a week, director or director/GS present at least 20% of operational hours. 55 Pa. Code §3270.241(c)(1)(i)
Based on the operator's statement, the director has not been present at the facility since 12/9/22 and has not been present at least 20% of the program's operational hours.
Center’s plan of correction (not implemented, Jan 27, 2023): “When inspector came on 12/20/22 director missed one week/ one day (20%) due to personal (illness) and professional interferences however she did come two days later on 12/22/22 for her shift.”
Inspection status on COMPASS: Non Compliant – Finalized
Citation
Dec 19, 2022
Inspection
Training & qualifications
Age and Training 55 Pa. Code §3270.31(e)
The file for staff person #1 lacked an annual of 12 clock hours of child care training.
Center’s plan of correction (implemented, Jan 27, 2023): “staff person #1 had some trainings in Pd that weren't printed, staff person #1 completed additional hours needed.”
Inspection status on COMPASS: Non Compliant – Finalized
Comply with CPSL/CPSL information 55 Pa. Code §3270.32(a)/3270.192(4)
The file for Staff person #2, with a hire date of 12/1/22 did not include the criminal history clearance listed as being completed on 11/6/20.
Center’s plan of correction (implemented, Mar 3, 2022): “Effective 3/3/2022 owner and director will put in effect that Kai may not return until her state police clearance is submitted.”
Citation
Feb 22, 2022
Inspection
Emergency preparedness
Training regarding plan/Exp, educ., training at facility 55 Pa. Code §3270.27(c)/3270.192(2)(iii)
The file for Staff person #2, with a hire date of 12/1/21, does not include verification of emergency plan training at hire.
Center’s plan of correction (implemented, Mar 8, 2022): “Owner will have emergency plan signed and placed in file by 3/6/2022.”
Citation
Feb 22, 2022
Inspection
Health & medication
Completed or signed by physician, PA, or CRNP 55 Pa. Code §3270.131(c)
The health assessment on file for Child #5 does not include a date of the exam, making it invalid.
Center’s plan of correction (implemented, Mar 14, 2022): “Student's parent/ guardian was unable to rectify validation of health form and signature and due to this I had to remove student from care until this is validated. The parent/guardian was made aware via email and verbally that child cannot return until this issue is resolved. This is effective…”
Citation
Feb 22, 2022
Inspection
Health & medication
ACIP recommended immunization record 55 Pa. Code §3270.131(e)
The immunization record on file for Child #2 and #4 are dated more than 60 days after enrollment.
Center’s plan of correction (implemented, Mar 3, 2022): “Child 2 and 4 have shot records on file and updated.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Arrival/departure times 55 Pa. Code §3270.123(a)(4)
the agreement on file for Child #2 does not include the child's arrival and departure times.
Center’s plan of correction (implemented, Mar 8, 2022): “Owner will have parent fill out proper times for arrival and departure on form 3/3/2022.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Admission date/Application, admission, withdrawal dates 55 Pa. Code §3270.123(a)(6)/3270.182(2)
The agreement on file for Child #1 and #3 does not include the child's date of admission.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner and Director will make sure all lines on forms are filled out properly and dated as of 3/3/2022.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Physician name, address, phone 55 Pa. Code §3270.124(b)(2)
The emergency contact form on file for Child #2 and Child #5 does not include the address and/or telephone number for the child's physician/source of medical care.
Center’s plan of correction (implemented, Mar 8, 2022): “Director and Owner will have parents fill out doctor and address info on forms for child 2 and child 5 effective 3/3/2022.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Parent home/work address, phone 55 Pa. Code §3270.124(b)(3)
The emergency contact form on file for Child #1, #2, and #3 does not include the address or telephone number for the enrolling parent's workplace.
Center’s plan of correction (implemented, Mar 8, 2022): “Owner and Director will have parents for Child 5, Child 3, and Child 2 fill out forms correctly to add information for home and work addresses effective 3/3/2022.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Written consent/Consent for emergency medical care required prior to admission 55 Pa. Code §3270.124(b)(4)/3270.182(3)
The file for Child #5 does not include written parental consent for the facility to obtain emergency medical care.
Center’s plan of correction (implemented, Mar 14, 2022): “the parent will be asked to give written consent to seek emergency medical care if necessary.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Insurance coverage information 55 Pa. Code §3270.124(b)(6)
The emergency contact form on file for Child #2 does not include the name of the health care insurance coverage. The emergency contact form on file for Child #3 does not include the policy number for the child's health care insurance coverage. The emergency contact form on file for Child #5 does not include the name of the health care insurance coverage or the policy number.
Center’s plan of correction (implemented, Mar 8, 2022): “Owner and Director will make parents fill out insurance info and policy numbers for Child #2, #3, and #5, effective 3/3/2022.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Name/address/phone release person 55 Pa. Code §3270.124(b)(7)
The emergency contact form on file for Child #2, #3, and #4 does not include a complete address for all listed release persons.
Center’s plan of correction (implemented, Mar 14, 2022): “Owner and Director will have parents of child 2 3 and 4 correctly fill out emergency contact forms with proper address for emergency contacts.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Consent for administration of minor first-aid required prior to admission 55 Pa. Code §3270.182(5)
The file for Child #5 does not include written parental consent for the facility to administer minor first aid procedures.
Center’s plan of correction (implemented, Mar 14, 2022): “The parent will be asked for written consent for the facility staff to administer minor first aid procedures.”
Citation
Feb 22, 2022
Inspection
Records & paperwork
Two written references 55 Pa. Code §3270.192(5)
The file for Staff person #2 only includes 1 written nonfamily reference letter
Center’s plan of correction (implemented, Mar 14, 2022): “Director and Owner will place 2nd reference of Staff person #2 in file effective 3/6/2022.”
Citation
Dec 16, 2021
Inspection
Emergency preparedness
Plan posted 55 Pa. Code §3270.27(d)
The provider did not have the emergency plan posted or available for review by the certification representative in the facility at the time of inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner/Director has emergency plan posted on parents information board set up and displayed by parent pick up entry way to be easily seen. A copy was sent to inspector via email/scan on 2/19/2022.”
Citation
Dec 16, 2021
Inspection
Transportation
Safe routes posted 55 Pa. Code §3270.171(c)
Safe drop-off and pick-up procedures were not posted in a conspicuous location for parents and visitors to review.
Center’s plan of correction (implemented, Mar 3, 2022): “Safe Pickup/ Drop off procedures are posted in parent information board which is easily accessible by parents by main entrance during pick up. They are also listed in parent guide book. This was in effect 12/21/2021. Owner emailed/scanned pickup/drop off procedures to inspector 2/19/2022.”
Citation
Dec 16, 2021
Inspection
Emergency preparedness
Written record 55 Pa. Code §3270.94(a)(9)
There was no fire drill log on file at the facility available for review at the time of inspection.
Center’s plan of correction (implemented, Feb 22, 2022): “Owner/Director has Monthly Fire drill log in file bin and it's also stored electronically for easy access that is updated monthly (after our drill) for inspector, staff, and school personnel if needed. This went into effect 12/21/2022.”
Citation
Dec 16, 2021
Inspection
Transportation
Pick-up and drop-off points 55 Pa. Code §3270.171(a)
The provider did not have verification of notifying traffic safety authorities in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.
Center’s plan of correction (implemented, Feb 22, 2022): “Owner/Director notified safety authorities at the beginning of the school prior to opening 8/25/2021 about facility use of pedestrians and vehicle routes used and it was signed and dated on 8/25/2021 by the Sargent in charge. Owner sent a copy via email/scan to inspector 2/19/2022.”
Citation
Dec 16, 2021
Inspection
Records & paperwork
On file at facility 55 Pa. Code §3270.18(a)
The provider did not have verification of the general liability insurance to cover individuals on file and available for review at the facility at the time of inspection.
Center’s plan of correction (implemented, Feb 22, 2022): “Owner has sent out via scan/email, insurance information to show coverage for the building, staff, and students. This was done on 2/19/2022.”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Posted in group space 55 Pa. Code §3270.111(b)
There was no daily activity schedule posted in the facility at the time of inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner/ Director has posted on Parent information board daily activities and schedule. Board is easily accessible by parents in entry way during pick up. This was effective 12/21/2021. This was also emailed to parents and given in printed form at the beginning of the school year 9/13/2021 (different…”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Each child care space 55 Pa. Code §3270.124(c)
There were no emergency contact forms for any enrolled child on site at the time of inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner/Director has made sure all appropriate staff has keys to unlock file cabinets with private family information concerning students and or staff in the form of emergency contact forms. This information is locked in a file bin because of sensitive information like address birthdates etc. These…”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Written emergency plan posted 55 Pa. Code §3270.124(e)
There was no emergency transportation plan posted on site at the time of the inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner/Director has parents information board set up and easily seen by entry way for parent pickup with information regarding emergency transportation plan. That change went into effect 12/21/2021. Owner emailed pictures of parent information board with emergency transportation plan posted to…”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Each child 55 Pa. Code §3270.181(a)
The child files were not on site and the provider could not access them at the time of the inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Children files are locked in file bin in the locked cabinet. All appropriate staff now have keys and access to file bin and cabinet.This was effective 12/21/2021. Owner scanned the list of children/students files that were given upon request which included shot records, health assessments, payment…”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Individual Records 55 Pa. Code §3270.191
There were no staff files on site and the provider was not able to access them at the time of the inspection.
Center’s plan of correction (implemented, Mar 3, 2022): “Staff files are locked in file bin in the locked cabinet. All appropriate staff now have keys and access to file bin and cabinet. This was affective 12/21/2021. Owner scanned two files that were requested her self and Kai Dawkins with all information needed. This was done 2/19/2022.”
Citation
Dec 16, 2021
Inspection
Records & paperwork
Availability of certificate of compliance and applicable regulations 55 Pa. Code §3270.25(a)
The current certificate of compliance was not posted in the facility at the time of inspection. The provider did not have verification of providing parents of enrolled children with information on how to access the regulations, Chapter 3270.
Center’s plan of correction (implemented, Mar 3, 2022): “Owner/Director has parents information board set up and easily seen by entry way for parent pickup with information regarding regulations Chapter 3270 also I have the scan code posted for easy accessibility via phone app. That change went into effect 12/21/2021. Brandis Care with Love LLC…”
Comply with CPSL/CPSL information 55 Pa. Code §3270.32(a)/3270.192(4)
The file for Staff person #1 does not a valid signed disclosure statement.
Center’s plan of correction (implemented, Sep 7, 2021): “Staff person #1 will complete a new disclosure statement to be submitted to the office.”
Citation
Aug 18, 2021
Inspection
Emergency preparedness
Emergency plan 55 Pa. Code §3270.27(a)(1)
The emergency plan does not include lockdown procedures.
Center’s plan of correction (implemented, Sep 7, 2021): “Emergency plan will include a lock down procedures.”