Chesterbrook Academy · 417 W Frederick St, Lancaster

Staff persons #1 and #2 were responsible for a group of 13 children. When asked to identify their care groups, the staff accounted for 12 of the 13 children in the room. 1 child was unaccounted for in the care groups. Staff persons #3 and #4 were responsible for a group of 11 children. When asked to identify their care groups, the staff accounted for 10 of the 11 children in the room. 1 child was unaccounted for in the care groups.

1st room on left - The pipe underneath the sink in the boy's bathroom was leaking water. In addition, loose cords were observed in the area that were running into a battery pack (sink operates on a sensor).

At the time of the verification visits for the renewal visit (SIN-00263187), areas of peeling paint were again observed throughout the building. (All CORRECTED ON SITE) -The door at the entrance to the child care facility. -Right side infant room, on the wall near the kitchen -Door frames into child care spaces throughout the facility -Beginners 2 - window sill and window frame -1st on left - in the prep space near the soap dispenser, and multiple spots in the boy's bathroom near the sink. -Last room on right, large area on far wall near bulletin board.

Staff persons #1 and #2 were present with a group of 18 preschoolers. Staff person #1 identified 8 of the children as being in her care group, and staff person #2 identified 9 of the children as being in her care group. One child was unaccounted for in the care groups.

Staff persons #3 and #4 were present with a group of preschoolers at lunchtime. The staff were not serving milk to all of the children and allowing them to choose water instead of the daily product.

Staff person #1 has fallen asleep while caring for and while holding infants.

Facility self-reported the following: After child #1 threw a piece of his lunch food and refused to clean it up, the child was sent away from the table. The child was not given time to eat the remainder of his lunch. Staff persons #1 and #2 were present with the group of preschoolers.

Staff person #1 - An updated mandated reporter training was not completed within 60 months. The trainings on file were dated 5/16/2019 and subsequently more than 60 months later on 11/18/24. Staff person #2 did not have a current mandated reporter training on file. The most recent training on file was more than 60 months old (dated 3/27/2020). In addition, an updated NSOR was not obtained within 60 months. The previous NSOR was dated 11/19/2019, and an updated clearance was not on file until 11/22/24. Staff person #2 worked during the time the NSOR was expired. Staff person #4 - An updated mandated reporter training was not completed within 60 months. The trainings on file were dated 6/24/19 and subsequently more than 60 months later on 11/15/24. In addition, updated state police, child abuse, and DHS FBI clearances were not obtained within 60 months. The child abuse clearance expired 6/21/2024, but was not updated until 11/2/24. The state police clearance expired 6/20/2024, but was not updated until 11/4/24. The DHS FBI clearance expired 6/26/2024, but was not updated until 11/6/24. Staff person #2 worked during the time the clearances were expired. Staff person #8 - The NSOR on…

1st room on left - The staff person present in the classroom was unable to see all of the children at naptime.

Left side infant room - An infant was observed sleeping soundly on a boppy pillow on the floor. Another infant was observed sleeping in a bouncy seat. The staff did not move the infants to their rest equipment once they were sleeping.

Intermediates 1 - A container of cleaning solution was not labeled. (CORRECTED ON SITE) 1st room on left - A container of bleach water cleaning solution was not labeled. (CORRECTED ON SITE)

5th room on right - The water temperature in the sink measured at 113° F. (CORRECTED ON SITE) Beginners 1 - The water temperature in the sink measured at 113° F. (CORRECTED ON SITE) Beginners 3 - The water temperature in the sink measured at 117° F. (CORRECTED ON SITE)

A backpack containing a first aid kit was stored in an area accessible to the children on the playground. (CORRECTED ON SITE)

The first aid kit in Beginners 1 did not contain tweezers.

5th room on right- The wall and baseboard near the children's sink was visibly soiled. Intermediates 1 - The barrier on the bathroom door (in place to prevent pinched fingers) was cracked. (CORRECTED ON SITE)

Areas of peeling paint were observed throughout the building. -The doorframe at the entrance to the child care facility. -Right side infant room - On the wall near the kitchen -3rd floor - behind the sink in the child care space -Door frames into child care spaces throughout the facility -Beginners 2 - window sill and window frame -1st on left - in the prep space near the soap dispenser, and in the boy's bathroom near the sink. -Intermediates 1 - Near the doorknob on the door to the bathroom

1st room on left - Children were observed resting on cots that had less than 2 feet of space around three sides.

The most recent health report on file for child #1 was more than 12 months old (dated 2/2024). Health reports on file for child #4 were dated in March of 2023, and subsequently more than 12 months later in April of 2024.

The immunization record on file for child #5 is not in accordance with the schedule recommended by the ACIP. The child's record does not include documentation of the child receiving their 3rd dose of the polio vaccine.

Right side infant room - A staff person was observed changing a child's diaper. The staff person did not wash the child's hands after the diaper change.

Staff person #5 - Health assessments were dated in August of 2022, and subsequently more than 24 months later in January of 2025. Staff person #10 - The record for staff person #10 did not include results of a TB test. Staff person #13 - The record did not include an initial health assessment.

The operator was unable to provide documentation of the proof and date of purchase of an interconnected fire detection device or system.

The initial health report on file was dated more than 60 days after the child's first day of attendance at the facility. The child began in care in July of 2024, but the initial health report was not on file until December of 2024.

The record for staff person #6 did not include documentation that the staff person had completed fire safety training during the past year. The most recent training on file was from February of 2024. The fire safety trainings on file for staff person #7 were dated in August of 2023, and subsequently more than 12 months later in April of 2025.

Staff person #9 has not received a completed staff evaluation in the past 12 months.

Child #3 has been enrolled for more than 12 months. The child's record included just 1 incomplete Child Service Report from the previous year. Child #4 has been enrolled fore more than 12 months. The child's record included just 1 CSR from the previous year, dated 12/24.

Emergency contact persons were not listed on the emergency contact form for child #2.

The emergency contact information on file for child #4 did not include the work phone number for the enrolling parent (CORRECTED ON SITE).

The emergency contact form on file for child #3 was updated in March of 2024 and subsequently more than 6 months later in January of 2025. The emergency contact form on file for child #4 was updated in April of 2024 and subsequently more than 6 months later in January of 2025

Emergency contact forms were past due to be updated in the following spaces. -5th room on right: 6 need to be updated -Beginners 2: 4 need to be updated -1st room on left: 3 need to be updated -Toddler 2: 1 needs to be updated -Toddler 3: 2 need to be updated -Interm 1: 4 need to be updated -Interm 2: 2 need to be updated -Beginners 1: 1 needs to be updated -Beginners 3: 1 needs to be updated

The record for staff person #3 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #1 completed 7 hours of annual training during the previous training year. Staff person #7 completed 9 hours of annual training during the previous training year. Staff person #11 completed 10.5 hours of annual training during the previous training year. Staff person #12 completed 7 hours of annual training during the previous training year.

Staff persons #1 and #2 were present in Intermediates 1 with a group of 20 preschoolers. Staff person #1 identified 9 of the children as being in her care group, and staff person #2 identified 10 of the children as being in her care group. One child was unaccounted for in the care groups. Upon second questioning, staff person #1 included the remaining child in her group.

Facility self-reported: On the afternoon of 2/6/25, staff person #1 was transitioning a group of 3 toddlers from the Toddler 2 room to the next-door Toddler 1 room. After staff person #1 entered the room, a parent found child #1 (young toddler) in the hallway unsupervised. Staff person #1 was unaware the child had walked away and reported not closing the door after entering into the room.

Staff person #1 did not compete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. The training was completed 122 days after the date of hire.

Peeling/water damaged paint was observed on the wall near the edge of the bathroom counter in the Beginners 1 room.

From June 5, 2024 through October 25th, 2024, 46 incident reports have been completed for child #1. The child's parent did not receive at least 7 of the 46 incident reports on the day of the incidents. 7 of the incident reports were not in the accident file. None of the incident reports were found in the child's file. Staff reported not writing incident reports after every time child #1 banged his head off of the floor.

Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child…

A complete state police clearance was not on file for staff person #10.

Staff persons #1 and #2 were present with a group of 20 preschoolers. The staff were unable to identify which specific children they were each responsible for. Staff persons #3 and #4 were present with a group of 12 older toddlers. The staff persons identified 6 children in each of their care groups, but 1 child was accounted for in each group. One child in the group was not accounted for. Staff persons #5 and #6 were present with a group of 10 young toddlers. 8 of the children were accounted for when staff identified which children they were each responsible for. Staff persons #7 and #8 were present with a group of 10 young toddlers. 9 of the children were accounted for when staff identified which children they were each responsible for.

More than 2 hours lapsed between diaper changes on multiple occasions for child 1. -On 9/10/24, the report stated the child's diaper was checked and dry at 11:46am and then she was changed more than 2 hours later at 2:55pm (woke from nap at 2:11pm). -On 9/11/24, the report stated she was changed at 9:45am and then more than 2 hours later at 12:12pm. The next diaper change was more than 2 hours later at 3:20pm (woke from nap at 2:08pm). The last diaper change of the day was more than 2 hours later at 5:29pm. -On 9/12/24, the report stated she was changed at 11:00am and then more than 2 hours later at 3:15pm (woke from nap at 2:20pm). -On 9/16/24, the report stated she was changed at 9:52am and then more than 2 hours later at 3:05pm (woke from nap at 2:37pm). -On 9/19/24, the report stated she was changed at 11:13am and then more than 2 hours later at 3:14pm (woke from nap at 2:33pm). -On 9/20/24, the report stated the child's diaper was checked and dry at 12:10pm and then changed more than 2 hours later at 3:08pm (woke from nap at 2:31pm). -On 9/24/24, the report stated she was changed at 12:10pm and then more than 2 hours later at 3:29pm (woke from nap at 2:40pm). -On 9/26/24, the…

A discarded cigarette was observed on the toddler playground while children were playing in the area. An open and full can of beer was observed sitting on the ledge within reach of the preschool aged children lining up outside of the playground.

A stepping stone located on the preschool playground was broken. It was cracked in multiple areas, creating sharp edges. (CORRECTED ON SITE)

32 days lapsed between the manual tests of the fire detection system that took place on 8/22/24 and subsequently 9/23/24.

Child 1, a young toddler, received 5 injuries at the facility in approximately a 6 week period. The child's parents did not receive the original of completed incident reports on the day of the incidents for at least 4 of the 5 incidents. The facility's accident file included just two of the five reports. The child's file did not include any incident reports.

Staff person 9 was observed caring for children. The staff on site were unable to provide certification staff (agent of the department) with a file for the staff person at the time of inspection. The staff person was helping for the day as she typically works at another location.

A broken glass windowpane was observed in Intermediates 2.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.77a on SIN-00243166 had not been fully implemented. On 5/15/24, peeling paint was observed behind the sink in the Intermediates 1 room, on a windowsill in Intermediates 2, and below the sink the Beginners 1. On 7/3/24, the peeling paint was still observed on the windowsill in Intermediates 2, and below the sink the Beginners 1.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.102a on SIN-00243166 had not been fully implemented. On 5/15/24, baseboards in classrooms and bathrooms throughout the facility were dirty/dusty. On 7/3/24, the baseboards in classrooms and bathrooms throughout the facility were still dirty/dusty.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.107 on SIN-00243166 had not been fully implemented. On 5/15/24, the thermometer located in the refrigerator in the 2nd floor infant room was reading at 48° F. On 7/3/24, the thermometer located in the refrigerator in the 2nd floor infant room was reading at 46° F.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(3) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact information on file for children 1, and 8 did not include the work addresses and work telephone numbers of the enrolling parent. On 7/3/24, the emergency contact information on file for children 1, and 8 still did not include the work addresses and work telephone numbers of the enrolling parent.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(4)/3270.182(3) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact forms on file for child 3 did not include written consent signed by a parent for emergency medical care. On 7/3/24, the emergency form on file for child 3 still did not include written consent signed by a parent for emergency medical care.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(7) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact information on file for child 4 did not include complete contact information for listed release persons (missing a complete address for the listed release person). On 7/3/24, the emergency contact information on file for child 4 still did not include complete contact information for listed release persons (missing a complete address for the listed release person).

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.181(c)/3270.181(e) on SIN-00243166 had not been fully implemented. On 5/15/24, a portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 - toddler 3. On 7/3/24, a portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 - toddler 3.

At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.182(5) on SIN-00243166 had not been fully implemented. On 5/15/24, the record for child 3 did not contain signed parental consent for administration of minor first-aid procedures by facility staff. On 7/3/24, the record for child 3 did not contain signed parental consent for administration of minor first-aid procedures by facility staff.

According to documentation on file at the time of inspection, when staff person #1 began work in the facility, the staff person's record did not contain completed child abuse clearance information required under the CPSL and did not contain a copy of the requests for a remaining out-of state clearance as required for provisional hiring under the CPSL. The staff person worked beyond a 45 day provisional hire period with incomplete clearances on file. The child abuse clearance was obtained 2 days after start date. At the time of inspection, the missing out of state clearance was not on file. (CORRECTED ON SITE) Facility person 8's rap sheet was not submitted to the regional office for review at the time of hire. According to documentation on file at the time of inspection, when staff person #13 began work in the facility, the staff record did not contain a complete NSOR clearance as required under the CPSL and did not contain a copy of the requests for the NSOR clearance as required for provisional hiring under the CPSL. According to documentation on file at the time of inspection, when staff person #16 began work in the facility, the staff record did not contain a complete Child…

Staff person 9 asked a child, "Do you know why you are at the front of the line? Because you weren't listening." The comment was loud enough for the other children to hear.

The facility did not have documentation that staff person 11 had been trained on the emergency plan.

A cleaning material (bleach water) was observed in an area accessible to the children in the 1st room on the left. (CORRECTED ON SITE) Sanitizer was observed in an area accessible to the children in the Intermediates 1 room. (CORRECTED ON SITE)

Peeling paint was observed behind the sink in the Intermediates 1 room, on a windowsill in Intermediates 2, and below the sink the Beginners 1.

Toy shelves in Intermediates 2 were visibly dirty/dusty. Baseboards in classrooms and bathrooms throughout the facility were dirty/dusty.

Pom Poms (diameter of less than 1 inch) were observed in the sensory table (accessible to children) in Beginners 2 (toddler classroom).

The thermometer located in the refrigerator in the 2nd floor infant room was reading at 48° F. The refrigerator located in the one-year-old room (next to 2nd floor infant room) contained a bin filled with old water and a mold-like substance. (CORRECTED ON SITE)

The updated health assessments on file for children 2 and 7 were not obtained timely. The health reports for child 2 were dated in September of 2022, and subsequently more than 12 months later in November of 2023. The health reports for child 7 were dated in June of 2022 and subsequently more than 12 months later in February of 2024. The children were older toddlers or preschoolers at the time of the lapse.

The records for children 1, 4, 6, 8, 9 and 10 did not include documentation that the children were vaccinated according to the ACIP schedule (or appropriate exemption notes) by the 60 day mark. The children remained in care during the time of the lapse in documentation. The records have since been obtained.

Intermediates 1 - A child was observed opening a trash can with their hands and disposing of their pullup into the trash can. Beginners 3 - A diaper was observed in an unlidded trash can. The trash can by the changing table was unlined.

The updated health assessment on file for staff persons 6 and 7 were not obtained timely. Staff 6 - The health assessments were dated in November of 2021, and subsequently more than 24 months later in May of 2024. Staff 7 -The health assessments were dated in September of 2021, and subsequently more than 24 months later in October of 2023.

The health assessments on file for staff persons 7 and 15 did not include an examination for communicable diseases and the results of that examination, nor the physician's or CRNP's assessment of the person's suitability to provide child care. The health assessment on file for staff person 18 does not include the physician's or CRNP's assessment of the person's suitability to provide child care.

A child's lunchbox was observed in her cubby in pre-k 1. The lunchbox contained potentially hazardous food. (CORRECTED ON SITE)

Initial health reports were not obtained within 60 days for children 1, 4, 6, 8, 9, and 10. They were obtained late for children 1, 6, 8, and 9. The records for children 4, and 10 still did not include health reports (CORRECTED ON SITE).

Staff persons 2 and 11 have not received a written evaluation in the past 12 months. Staff persons 3, 5, and 7 - Written evaluations were due in May of 2023, but the evaluations were completed late in June of 2023. Staff 4 - Written evaluations on file were dated in May of 22 and subsequently more than 12 months later in July of 2023.

Staff person 9 is serving as a GS at the facility. The staff record does not include documentation that the staff person has attained one of the qualification levels specified at §3270.35(b)(1)-(4)

Staff persons 10, 12, and 15 are serving as assistant group supervisors at the facility. Their records include documentation of high school diplomas, but do not include documentation of 2 years (2,500 hours) of child care experience.

The agreements on file for children 5 and 9 each were not signed by the operator.

The records for children 2, 4, 5, 7, 8, and 10 did not contain documentation that Child Service Reports (or another approved form) was being completed at least every 6 months.

The agreement on file for child 4 did not specify the child's arrival and departure times.

The agreements on file for children 4, 5, and 9 did not specify the date of the child's admission.

Originals of agreements were on file for children 1, 2, 4, 5, 7, 9, and 10. There was no agreement on file for child 3. Copies of initial agreements were not on file for children 1, 6, and 9. Child 1 - first agreement on file dated 3 months after start date. Child 6 - first agreement on file dated 3.5 months after start date. Child 9 - first agreement on file dated 1.5 months after start date.

The emergency contact information on file for children 3 and 10 each did not include a phone number for the child's physician or source of medical care.

The emergency contact information on file for children 1, 4, 8, 9, and 10 do not include the work addresses and work telephone numbers of the enrolling parent. The emergency contact information on file for child 5 did not include the work telephone number of the enrolling parent.

The emergency contact forms on file for children 3, 8, 9, and 10 each did not include the written consent signed by a parent for emergency medical care

The emergency contact information on file for children 1 and 5 each did not include the child's health insurance policy number. The emergency contact information on file for children 6, 8, and 9 each did not include the child's health insurance coverage and policy number.

The emergency contact information on file for children 4 and 10 did not include complete contact information for listed release persons. -Child 4 - missing a complete address for the listed release person. -Child 10 - missing addresses and phone numbers for listed release persons

The written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not displayed conspicuously in Pre-k 1 and in Toddler 3. (CORRECTED ON SITE)

A portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 -pre-k 1 -toddler 3

Emergency contact forms and/or financial agreements were not updated timely during the previous year for children 3, 4, 8, and 10. Children 3 and 10 - Emergency contact forms past due for update - most recently signed in August of 2023. Child 4 - 8 months lapsed between updates of the emergency contact form Child 8 - 7 months lapsed between updates of the emergency contact form and financial agreement.

The record for children 3, 8, 9, and 10 each did not contain signed parental consent for administration of minor first-aid procedures by facility staff.

The record for staff person 14 included one written, nonfamily reference. The second reference on file was written by a relative. The record for staff person 17 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

The record for staff person 7 included documentation of 4 clock hours of child care training from the previous year.

Staff person #1 left [3 year old] child #1 alone on the facility's playground for a period of approximately 3-4 minutes.

The facility self-reported the following incident: At 11:43 am on 8/24/23, staff person 1 transitioned a group of preschoolers from their room to combine with another group of children in a neighboring room. During the transition, child 1 was able to walk away from the group un-noticed and return to the empty room. The child was unsupervised in the room for 8 minutes before being found by staff person 2.

The facility self-reported: On 6/1/2023, staff persons 1 and 2 were transitioning a group of older toddlers to the playground when child 1 was left behind in the Beginners 3 room. Staff 1 and 2 realized the child was not with the group when they got to the bottom of the stairwell and staff person 3 ran up to the room and found the child alone in the classroom. Facility staff estimated that the child was alone for approximately 2 minutes.

During the corrections verification visit for SIN-00223808, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).

During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Intermediates 1 - Ceiling tile in the restroom showed evidence of a water leak (staining).

During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: A children's chair located in Beginners 1 was in poor repair. The surface of the chair was peeling, and the inner foam was exposed through the holes.

During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).

At the time of inspection, the record for staff person 2 did not include a criminal history clearance for a state the individual resided in during the past 5 years. (CORRECTED ON SITE)

A toddler was observed painting with shaving cream.

Intermediates 1 - Ceiling tile in the restroom showed evidence of a water leak (staining).

Areas of peeling paint were observed in the following spaces: Pre-k 1 - Near block area Beginners 2 - Near book area Intermediates 2 - Baseboard near sink

The was not a visual strip or other visual identification placed on glass door entering into the Intermediates 1 room.

A children's chair located in Beginners 1 was in poor repair. The surface of the chair was peeling, and the inner foam was exposed through the holes.

The record for staff persons 1 did not include the Pennsylvania Health and Safety update training which was to be completed by 12/30/2022 per Announcement C-22-06.

The emergency contact information on file for child 3 did not include the address and telephone number of the child's physician or source of medical care.

The emergency contact information on file for children 1, 2, and 3 did not include the following information: Child 1: Enrolling parent's work address and telephone number Child 2: Enrolling parent's work telephone number Child 3: Enrolling parent's work address

The emergency contact information on file for child 2 did not include an address for a listed release person.

Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).

Staff person #1 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.