Chesterbrook Academy · 132 N Pointe Blvd, Lancaster

Staff persons #3 and #4 have not completed the mandated reporter training within 90 days of their date of hire (see code sheet). Staff person #1 and #2 were observed to be caring for children unsupervised. Staff person #1 and #2 have not completed the pre-service training (Health and Safety training) required prior to caring for children unsupervised. Staff person #4 has not completed part 2 of the Health and Safety training and has been working for more than 90 days at the facility. See Code Sheet

Staff person #2's record did not contain NSOR clearance results. Staff person #2's NSOR clearance request submission was dated 5/12/25, which was after this staff person began working at the facility. (see code sheet). Staff persons #3 and #4 have not completed the mandated reporter training within 90 days of their date of hire (see code sheet).

The time between fire drills exceeded the permitted at least every 60 days' timeframe (5/15/25, 8/1/25).

The testing of the facility's fire detection system exceeded the permitted at least every 30 days' timeframe (6/12/25, 8/1/25).

Staff persons #1 and #2's records did not contain verification of education and experience, and both were acting as Assistant Group Supervisors. Staff person #4's record did not contain the verification of experience required to be acting as an Assistant Group Supervisor, yet has been caring for children unsupervised.

Staff person #2's file did not contain an initial health assessment including the results of an initial TB skin test, x-ray or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Staff person #1 and #4's records did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #1 gave child #1 (infant) 2 ounces of water, which was not included in the parent's written feeding schedule provided to the facility.

Staff persons #1 and #2 were unaware that child #1 had left the classroom and was unsupervised in the facility for approximately 30 seconds.

Staff person #1's file did not contain the NSOR clearance (corrected during inspection). Staff person #1's Disclosure Statement was not witnessed.

Staff person #2's health assessment did not include an examination for communicable diseases and the results of that examination and also did not include information on medical problems that might threaten the health of the children or prohibit a staff person from providing adequate care to children.

The time between conducted fire drills exceeded the at least every 60 days' timeframe (most recent drill dated 3/11/25) Fire drill was conducted during this visit.

Staff person #2 does not have the required education on file to act as a Group Supervisor, yet has been utilized as one.

Staff persons #1 and #2 are being utilized as assistant group supervisors without verification of at least 2 years of experience working with children on file.

Staff person #1's record did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #3's record did not contain the NSOR clearance results or proof that the clearance request was submitted See Code Sheet.

It was observed, in the Beginner B classroom, that staff was not able to supervise children during naptime due to classroom furniture obstructing their view (corrected during inspection).

Staff person #1 did not receive emergency plan training within the first 90 days of employment. See code sheet.

It was observed that the Village Room (gross motor space) was also set up with tables and chairs for fine motor activities.

In the PreK2/SA classroom, a plug-in, liquid Airwick air freshener was observed to be plugged in and accessible to children (corrected during inspection).

It was observed that trash that is contaminated with human secretions is not contained in closed receptacle in the Beginner A, PreK, and PreK 2 classrooms.

Dirty trashcans were observed in the Toddler A, PreK, Intermediate B, and PreK2/SA classrooms (corrected during inspection). Both sinks in the Intermediate B classroom were observed to be dirty. Three sinks in the Toddler A classroom were observed to be dirty (all sinks corrected during inspection). It was observed in the bathroom within the Village Room that there were 2 long panel shelves leaning against the wall (corrected during inspection).

It was observed, in the Beginner B classroom, that the play kitchen was missing a handle. The blue mat, in the reading area, in the PreK2/SA classroom, had a tear with the foam exposed. The blue mat tear was corrected during the inspection.

It was observed, in the Intermediate A classroom, that the blue vinyl couch had two tears on both armrests, with the foam exposed. The armrests on this couch are not fully secured to the main portion of the couch (partially torn away).

Child #1 (Beginner A classroom) has medication in the classroom, with no medication log completed.

There was no record of the operator notifying local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

The time between fire safety trainings on record for staff person #5 exceeded the permitted annual timeframe (1/19/24, 2/1/25).

The enrolling parents did not receive, in writing, the facility's supervisions policy and hours for which care is provided.

Staff person #2 and #4's records do not include verification of child care experience. Staff person #3's record does not contain verification of education and experience.

Staff person #2's file does not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #1 made a degrading comment about a child in care.

It was observed that the Custodial Closet was accessible to the children and contained the following toxins: 2 bottles of glass cleaner, a bottle of bleach, a bottle of multipurpose antibacterial cleaner. The accessible Staff Room contained Clorox spray, mold control, and glass cleaner, under the sink. (All corrected during inspection).

It was observed that the Staff Room was accessible to the children and contained die cuts (blades). Corrected during inspection

The documentation of testing the fire detection devices exceeded the permitted at least every 30 days' timeframe (most recent 11/8/24) Corrected during inspection.

Staff person #1's file did not contain proof of completing the required 10-hour Health and Safety Training and has been employed for more than 90 days. See Code Sheet

Staff person #1 did not supervise and did not know the whereabouts of child #1 when child was left in classroom bathroom while teacher and class went to the outdoor playground (approximately 10 minutes)

Staff person #1's record contained no clearances. During this visit, this staff person's FBI and PA Criminal Record Check clearances were located and placed in the staff file. Staff person #1 still has no NSOR and Child Abuse clearance on file.

The time between the testing of the fire detection devices exceeded the permitted at least every 30 days' timeframe (5/2/24, 6/26/24).

On 3/11/24, a toddler room (2 yr olds) was out of compliance regarding the required staff to child ratio. The ratio was 1 staff person for 9 children.

Staff person #3's previous FBI clearance results were not on record. Staff person #5's State Police and Child Abuse clearances are for the purpose of Foster Care rather than Employment, as is required. Staff person #5 had been working at this facility with these clearances on record from the 1st day working at facility until 2/19/24. SEE CODE SHEET.

It was observed in the PreK 2 room that, during naptime, the view of several children was obstructed by classroom furniture (corrected during inspection)

The emergency plan was not posted in the facility in a conspicuous location (corrected during inspection)

It was observed in the PreK 2 room that toxins were accessible to children under the classroom sink: bleach, sunscreen (corrected during inspection).

It was observed in the Toddler B room that the sanitizing solution was in a container that did not specify the contents (corrected during inspection).

It was observed that the first-aid kit in the Intermediate B classroom did not contain scissors (corrected during inspection)

It was observed in the Beg A classroom that there were three areas of peeling paint under the window on the left (one approx 6", one 2", one 12"). Also in the Beg A classroom, the paint on the floor molding (wall on left upon entering) had peeling paint.

It was observed in the PreK, Toddler A, and Beginner A rooms that the rest equipment was not labeled for the use of a specific child and used only by the specified child.

It was observed in the PreK 2 room that there was not 2 feet of space on three sides of the rest equipment when in use (corrected during inspection).

In the Beginner A classroom, Child #1's medication log did not include the date of administration and the time of administration of the medications for this child.

Staff person #2's file contained an initial health assessment dated 2/6/23, which is after providing initial service in the child care facility. SEE CODE SHEET

The menu was not conspicuously posted at the facility (corrected during inspection)

There was no documentation of conducting fire drills at the facility between February 2023 and 12/26/23.

There was no documentation of the testing of the fire detection devices since February 2023 to the date of this inspection (tested on date of inspection).

Child #7's initial health assessment is dated 12/27/22, which is greater than the permitted no later than 60 days following the first day of attendance at the facility. SEE CODE SHEET

There was no documentation of the operator notifying local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see Code sheet): 10 Hour Health and Safety Basics Training.

The records of child #4, #5, #7, and #10 do not contain the required documentation provided to the family with information about the child's growth and development in the context of the services being provided within the permitted every 6 months' timeframe. SEE CODE SHEET

The agreements of child #2, #3, #4, #5, #6, #7, #8, #10, and #11's do not include the date of admission.

The files of children #2 through #11 contained the original agreements. Parents did not receive the original agreements.

Child #6's emergency contact information does not include all release persons' addresses.

Staff persons #3 and #4 did not obtain the annual minimum of 12 clock hours of child care training.

Child #1 was not supervised by staff person #1 (or any staff person) when the child entered the building, from the playground, where the remainder of his class was.

Staff person #1 did not know the whereabout of child #1 when this child entered the building to use the bathroom without being supervised by another staff person.

Staff person #1 physically forced a child from standing position into sitting on the floor when the child would not listen to the teacher's request to get out of line.

Staff person #1 physically restrained child #1 by crossing the child's legs and placing hands over both of the child's legs while the child was sitting on the floor.

Staff person #1's record did not contain proof that all out of state clearances were applied for before working with children at facility. Staff person #1's file did not contain NSOR clearance results and did not contain DHS FBI clearance results (contained Dept of Education FBI clearance).

Staff person #4's Mandated Reporter training is dated beyond the permitted 90 days after the date of hire (12/30/22). See code sheet for date of hire. Staff person #6 lived in another state within the last 5 years and does not have that state's Child Abuse clearance on record. Staff person #7 has no NSOR on record and has lived in a different state within the last 5 years requiring that state's Child Abuse and Sex Offender clearances on record. Staff person #8 lived in a different state within the last 5 years and does not have the Child Abuse clearance from that state are on record.

It was observed, in the Infant room, that five tubes of diaper cream (keep out of reach of children) were accessible to the children under the diaper changing area (corrected during inspection). In the Pre-K 2 child care space, it was observed that there was an open bag of Miracle Grow accessible to children in the wooden cabinet on the wall upon entering the room (corrected during inspection). The staff bathroom (across from the office) contained the following toxins which were accessible to children: dry shampoo, deodorant, and perfume (keep out of reach of children). Near the 3 yrs and older outdoor play space (near the beginner's play space), there was an unlocked grey and tan shed which contained bleach and disinfectant spray (mold remediation) which was accessible to children. (corrected during inspection).

It was observed, in the Intermediate B classroom, that the water temperature of the classroom sink and the bathroom sink exceeded 110 degrees F (corrected during inspeciton).

It was observed, in an accessible children's bathroom that is not currently in use in the Toddler B room, that there were tables and shelves being stored upright against the wall.

It was observed that there were rocks (red) that were less than 1 inch diameter accessible to children who are still placing objects in their mouths on the path to the outside play area, near the entrance to the toddler outdoor play area. There were also multicolored rocks, against the building, which were less than one inch diameter, on the path that children who are still placing objects in their mouths utilize.

It was observed, in the Infant room, that the children who were seated in the highchairs were not wearing the seatbelts as is required by manufacturer's instructions (corrected during inspection).

It was observed, in the Beginner A classroom, that rest equipment was not labeled for the use of each specific child.

It was observed that the refrigerator in the Infant A child care space did not contain an operating thermometer (corrected during inspection).

Child #6's initial health report is not signed by a physician, physician's assistant or a CRNP.

Child #2's record does not contain proof receiving the Influenza immunization. Child #3, #4, #7, and #9's records do not contain proof of receiving the Influenza immunization within the last year (#3 9/27/21, #4 9/28/21, #7 11/6/19, #9 10/22/21).

In the Beginner classroom, a child had medication stored for use when needed, but no medication log was filled out by the parent.

It was observed, in the Toddler B child care space, that one child's medication log did not indicate the date of administration for the medication.

Staff person #6's initial health assessment was dated 1/18/23, which was after working directly with children. Staff person #7's initial health assessment was dated 2/22/23, which was after working directly with children. (See Code Sheet for DOH).

Testing of the fire detection system exceeded the permitted at least every 30 days timeframe (4/4/22, 5/24/22), (8/11/22, 9/16/22), (11/2/22, 12/22/22). The facility did not have proof of purchase on record for the interconnected fire detection system.

It cannot be determined if child #6's initial health report was received no later than 60 days following the first day of attendance at the facility due to it not being dated.

Staff person #10 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.

Staff person #1's record does not contain a staff evaluation for the last 12 months of employment.

Child #8 and #9's agreements are not signed by the operator.

Child #8's agreement does not specify the amount of the fee to be charged per day or per week.

Child #8's agreement does not specify the date on which the fee is to be paid.

Child #7 and #8's agreements do not specify the child's arrival and departure times.

Child #5's agreement does not specify the persons designated by a parent to whom the child may be released.

The agreements of children #1, 2, 3, 4, 5, 7, and 8 do not specify the date of the child's admission.

The agreements of children #1 through #9 do not specify the services which are to be considered as extra.

The emergency contact information for child #4 and #5 does not include the enrolling parent's home telephone number. The emergency contact information for child #5 and #6 does not include the enrolling parent's work telephone number.

It was observed, in the Infant room and the School-Age room, that there was no written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency conspicuously displayed (corrected during inspection).

The emergency contact information and financial agreement for child #7 were not updated once in a 6 month period (exceeded permitted 6 months' timeframe).

Staff person #4's record does not include verification of education. Staff person #5's record does not include the verification of experience required to be utilized an AGS. Staff person #9's record does not include verification of education required to be utilized as an AGS. Staff person #11's record does not contain verification of experience required to be utilized as an AGS.

Staff person #3's record does not contain an initial health assessment.

Staff person #2, #3 and #9's records do not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

The operator did not provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically (corrected during inspection).

Staff person #1 did not complete the required Health and Safety pre-service training within 90 days from the date of hire.

The file for staff person #3 did not contain a copy of the NSOR Clearance as required by the CPSL. The file for staff person #7 did not contain a copy of the final State Police Clearance, the document dated 09/07/2021 was verifying the request was under review.

The operator did not update the plan as needed; a new director was hired and this was not updated in the emergency plan.

The operator did not assure that staff person #1, #3, #5, and #6 received training regarding the emergency plan at the time of initial employment; emergency plan training was completed on 03/25/2022. The operator did not assure that staff person #4 received emergency plan training on an annual basis; the most recent emergency plan training was completed on 03/25/2022 with the previous training completed on 11/13/2020.

Observed a spray bottle on the counter located in the Beginner "B" classroom which did not have a label which specified the contents of the bottle.

Observed the emergency telephone numbers listed by the telephone in the classrooms did not include the number of the nearest fire department.

Observed the first aid kit located in the Intermediate "A" classroom did not include soap. The first aid kit located in the Toddler "B" classroom did not include scissors, tape, tweezers for an assortment of adhesive bandages.

Observed the bolts on the fence were protruding into the play space creating a visible hazard. Observed knobs on the cabinets located in the Beginner "B" classroom which were loose.

Observed the toilest in the bathroom shared by the Toddler "A" and Toddler "B" classroom was missing the plastic protective caps for the bolts at the base of the toilet.

Observed the toilets in the bathroom shared by the Toddler "A" and Toddler "B" classroom did not have handwashing signs.

Observed in the bathroom shared by the Toddler "A" and Toddler "B" classroom did not include a hands-free, lidded waste receptacle for the disposal of diapers & pull-ups.

Observed 2 tricycles on the playground without grips on the handles and tricycles with rust on the exposed metal parts.

The file for child #5, a young toddler, did not include an updated health report at least every 6 months; the most recent health report on file was dated 02/09/2021.

The file for child #4, an 11-month-old, included a record of the child's immunization status which lacked a 3rd DTap and a 3rd PCV13 immunization. The file for child #5, a 15-month-old, included a record of the child's immunization status which lacked a 2nd dose of HepB, 2nd dose of Rotavirus, 2nd & 3rd dose of DTap, a 2nd & 3rd dose of Hib, 2nd & 3rd dose of PCV13, and a 2nd dose Polio, an influenza, MMR and Varicella immunization. The file for child #7, 3 years old, included a record of the child's immunization status which lacked a current influenza immunization.

Observed prescription medication for child #1 which did not written consent from the parent for administration.

The diaper changing table located in the toddler "B" classroom did not have a hands-free covered can for the immediate disposal of soiled diapers.

The file for staff person #2 included a health assessment which was not updated every 24 months; the most recent health assessment on file was dated 02/12/2020; the subsequent health assessment on file dated 06/17/2021 was a letter from the physician and was not a complete health report. The staff health assessment on file for staff person #12 was not conducted within 12 months prior to providing initial service; the health assessment on file was dated 12/22/2020 which was greater than 12 months from their start date at the facility.

A written statement giving the formula and feeding schedule for child #2, an infant, was not obtained from the parent.

An annual emergency drill was not documented within the previous 12 months.

The Director or designated staff person did not maintain a written record of the fire drills conducted prior to January 2022.

The Director or designated staff person did not ensure a test of the fire detection system was documented every 30 days. A copy of the activity report from Yarnell Security Systems was kept on file in lieu of a manual test of the system every 30 days. *System was tested at the time of the inspection. A copy of the proof of purchase of the interconnected fire detection system was not with the facility's fire drill logs. An attestation statement was completed at the time of the inspection.

Pediatric First Aid & CPR for staff person #2 was not updated on or before the expiration; the current Pediatric First Aid & CPR was completed on 02/23/2022 and the previous training was valid from 11/23/2019 - 11/2021.

The file for staff person #2 lacked documentation of annual firesafety training; the most recent training on file was completed on 11/11/2020. The file for staff person #4 lacked documentation of annual firesafety training; the most recent training on file was completed on 11/17/2020.

The director did not ensure that a staff evaluation was completed for staff person #2 and #4 at least once every 12 months; the most recent staff evaluations for staff person #2 and #4 were completed on 01/23/2020.

The agreement for child #6 was not signed by the parent.

The agreement for child #3 did not specify the child's arrival and departure times.

The agreement for child #8 did not specify the date of the child's admission.

The emergency contact information for child #3 did not include the complete address of the child's physician or source of medical care.

The emergency contact information for child #4 did not include the address of the individuals designated by the parent to whom the child may be released. The emergency contact information for child #3 did not include the complete address of the individuals designated by the parent to whom the child may be released.

Emergency contact information was not present for all of the children receiving care in the Beginner "A" and Intermediate "A" classrooms. Corrected at the time of the inspection.

The file for staff person #12 did not include verification of child care experience and education prior to service at the facility.

The file for staff person #8, #9, #10 and #11 only contained one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person.

Pediatric first aid & CPR was not completed by staff person #3 and #5 within 90 days of hire; training was completed on 02/23/2022.