Downtown YMCA

On August 12, 2025 at approximately 11:45am in the Gym there were 19 young school age children in attendance. Staff #1 named 13 young school age children and Staff #2 named 4 young school age children, putting Staff #1 over ratio by 1 and making a 0-2 ratio for the 2 children that were not named.

On August 12, 2025 at approximately 11:45am in the Gym there were 19 young school age children in attendance. Staff #1 named 13 young school age children and Staff #2 named 4 young school age children, leaving 2 children not assigned to a staff person.

According to multiple staff statements, staff have been observed numerous times using their personal cellphones when in ratio, resulting in lack of supervision of the children in their care.

There was no documentation that Facility Person #1, serving as a lifeguard at an excursion at Camp Sherwin that included swimming, had been trained on the emergency plan in the previous 12 months.

The NSOR clearance on file for Facility Person #3 was completed after their first date of employment in a child care position (after 2/1/25.).

There were toxics (bleach water and other cleaning supplies) accessible to children in cabinets under sinks in the infant room and sensory room due to faulty locks on the cabinet doors.

There was a torn screen in an open window in the North Gym.

There was peeling paint / damaged plaster in the SACC room, near the floor under the windows, in the Kinderbear room on the wall near the sink, and in the Pre-K room where a gate is installed in the front part of the room.

There was no lidded trash can at one of the sink areas in the older toddler/preschool room.

There was a piece of play equipment in front of a door from the Shining Stars room, blocking the exit.

The current health assessment on file for child #6, a preschooler, dated 9/5/24, was completed more than 12 months after the previous health assessment on file for the child, dated 8/29/23.

As per the operator's statement, diapers/pull-ups worn by children in the older toddler/preschool room are changed in the changing area in the restroom across the hall from the classroom. There was no hands-free trash can for diaper disposal in that restroom changing area.

There was no written feeding schedule at the facility for one of the enrolled infants.

The child care operator is unable to test the fire detection system annually at the certification renwal inspection and at least every 30 days due to a valid reason. The most recent professional inspections of the fire detection systems documented and on file were completed on 2/9/24 and then again on 2/17/25, more than 12 months apart.

The initial health assessment on file for child # 7 was completed more than 60 days after their first day of attendance at the facility.

The current firesafety training completed and documented on file for Facility Person #1 was completed more than 12 months after the previous fire safety training.

Approved child assessments completed an on file for children # 1, #2, #3, #4, and #6 were not completed at least every 6 months.

The agreements on file for children #2, #4 and #5 did not specify the admission date.

The emergency contact form on file for child # 8 did not include the address of one of the release persons listed.

The medical emergency transportation plan in the Shining Stars room was placed on a shelf and toys had been placed on top of it, resulting in it not being posted conspicuously.

The initial first aid training completed and documented on file for Facility Person #2 was completed more than 90 days after their date of hire.

The facility's current certificate of compliance was not posted.

According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young school ager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young school ager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

***According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young schoolager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young schoolager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

****According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young schoolager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

**According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young schoolager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

*According to reports from the operator and video footage of the incident, on 11/11/24, at 2:50 PM, Facility Persons #1 and #2 were supervising 8 preschoolers and one young schoolager in the Shooting Stars room, when they both left the room with 8 of the 9 children to take them to the Older Toddler room in the infant/toddler wing. Child #1, a preschooler, remained behind in the room, unsupervised. The group left the fourth floor preschool wing and walked down to the first floor where they exited the building and re-entered in the infant/toddler wing. They arrived in the Older Toddler room at 2:57 PM. At 3:06 PM staff realized Child #1 was not in the Older Toddler room and Facility Person #1 left the Older Toddler room to return to the Shooting Stars room. Facility Person #1 arrived in the Shooting Stars room at 3:07 PM and retrieved the child, who was lying on the floor and appeared to be asleep.

On 10/9/2024 Facility Persons #1 and #2 were supervising schoolagers in the North Gym. Video footage of the self-reported incident shows Facility Person #1 roughly grabbing the arm of Child #1 after they pulled a ball out of a basket. Child #1 can be seen rubbing their arm as they walked away after the incident.

At approximately 3:35 on 10/25/24 in the Kinderbear Room, Facility Persons #1 and #2 were supervising a total of 22 schoolagers. Facility Person #1 claimed responsibility for 10 young schoolagers and 6 older schoolagers and Facility Person #6 claimed responsibility for supervising 6 older schoolagers.

At approximately 3:45 PM in the Older Toddler Room, Facility Persons #3 & #4 were supervising 16 preschoolers. When asked to identify which children they were each supervising, Facility Person #3 claimed 7 children and Facility Person #4 claimed 6 children. This totaled 13 of the 16 children present in the classroom. When asked again, each staff person claimed one additional child, saying the children had previously been assigned to a staff person who had left for the day. When it was pointed out that this totaled 15 of the 16 children, staff stated which child was not claimed by either staff person and Facility Person #4 indicated they would be responsible for the child.

At approximately 3:35 on 10/25/24 in the Kinderbear Room, Facility Persons #1 and #2 were supervising a total of 22 schoolagers. The maximum measured capacity of this room is 17 children.

There was no daily schedule posted in the Kinderbear Room.

Facility Persons #1 and #2 were supervising a group of 11 children swimming in a pool on an excursion at Camp Sherwin. When asked to identify which children they were supervising, Facility Person #1 claimed responsibility for 2 older schoolagers and 1 young schoolager. Facility Person #2 claimed responsibility for 8 of the children- 3 older schoolagers and 5 young schoolagers.

The current child abuse clearance on file for Facility Person # 1 was completed more than 60 months after the previous child abuse clearance on file. The criminal history clearance on file for Facility Person #4 was incomplete. The current criminal history clearance on file for Facility Person #5 was completed more than 60 months after the previous criminal history clearance. The only NSOR clearance and disclosure statement on file for Facility Person #5 were each dated over two years after their start date. The most recent mandated reporter training documented and on file for Facility Person #5 was completed more than 60 months after the previous mandated reporter training.

There were toys attached to the sides of cribs in the infant room, in reach of the infants who rest in the cribs.

There was no documentation of a review of the emergency plan prior to the most recent review date documented - 12/20/23.

The letter to the parents explaining the emergency plan does not address annual emergency drills.

There was an accessible uncovered outlet on the wall in the Toddler 2 room,

There were Clorox wipes, furniture polish, all-purpose cleaner in an unlocked low cabinet in the Hellberg room.

There was no first aid kit in the Cat room.

The first aid kit in the school age room did not include scissors. The first aid kit in the shooting stars room did not include soap or gloves.

The sink in the infant/toddler room at the diapering area was not equipped with a stool to allow able toddlers to reach the sink to wash their hands.

There were no handwashing signs at 2 toilets in the restroom off of the north gym.

There was climbing equipment in the Kids Court (Cout 6) play space not installed over protective surface covering.

The thermometer in the refrigerator in the Studio was not functioning properly.

The current health assessment on file for child #3 was completed more than 12 months after the previous health assessment.

The immunization record on file for child #5 indicates that the child did not have sufficient doses of the Hepatitis A vaccine as recommended by the ACIP for the age of the child.

The current health assessments on file for Facility Persons #2, #5, and #8 were completed more than 24 months after the previous health assessments on file. The initial health assessment on file for Facility Person #4 was completed more than 12 months after their start date. The negative chest xray results - after a positive TB test - documented and on file for Facility Person #3 was completed after their start date.

The menu was not conspicuously posted or shared with parents at least a week in advance.

The facility's emergency plan did not provide for accommodations for infants and toddlers in an emergency.

There was no documentation to show the emergency plan was sent to the local municipality

The initial health assessment on file for child #2 was completed more than 60 days after their first day of attendance.

There was no documentation on file to indicate that Facility Person #6, employed more than 90 days at the facility, completed the 1 hour health & safety training.

There was insufficient documentation of the education and/or child care experience on file required for the noted staff classifications of Facility Persons #5 and #6.

The current evaluation on file for Facility Person #2 was completed more than 12 months after the previous evaluation.

The daily activity schedule was not posted in the Cat room.

There were no child service reports - or other approved assessments - completed and a copy given to the parents within the last 6 months, on file for children #2 and #4. There was a CSR on file for child # 3 from 1/2023 and another that was not dated. The current CSR's on file for children #1 and #5 were completed more than 6 months after the previous assessments.

There was no health insurance policy number on the emergency contact form on file for child #3.

The emergency contact form on file for child #6 did not include the release persons' address and phone number.

The medical emergency transportation plan was not posted in the South Gym, the Cat room or the Hellberg room.

The emergency contact forms and agreements on file for children #6-#9 were not reviewed and updated by a parent in writing in the previous 6 months.

There was documentation on file of only 10 hours of child care training completed in the most recent review year for Facility Person #2.

According to staff statements, there were instances were children were not properly supervised when solely supervised by Facility Persons #1 and/or #2, when these staff were talking to each other or on their phones rather than paying attention to the children.

**According to staff statements, there were instances were children were not properly supervised when solely supervised by Facility Persons #1 and/or #2, when these staff were talking to each other or on their phones rather than paying attention to the children.

**Staff statements and video surveillance footage indicate that on 1/16/24 at approximately 4:00 PM, Facility Persons #1, #2, and #3 were supervising children in the infant room when Child #1, a young toddler, pulled Child #2's hair, also a young toddler. In response, Facility Person #1 lunged at Child #1, picked them up roughly, yelled at them, and put them down aggressively. Facility Person #2 then pulled Child #1's hair. Child #2 was then observed hitting Child #1 and pulling their hair while Facility Person #1 encouraged Child #2 by saying, "It's your turn now," and "Get them back."

Staff statements and video surveillance footage indicate that on 1/16/24 at approximately 4:00 PM, Facility Persons #1, #2, and #3 were supervising children in the infant room when Child #1, a young toddler, pulled Child #2's hair, also a young toddler. In response, Facility Person #1 lunged at Child #1, picked them up roughly, yelled at them, and put them down aggressively. Facility Person #2 then pulled Child #1's hair. Child #2 was then observed hitting Child #1 and pulling their hair while Facility Person #1 encouraged Child #2 by saying, "It's your turn now," and "Get them back."

Staff statements and video surveillance footage indicate that on 1/16/24 at approximately 4:00 PM, Facility Persons #1, #2, and #3 were supervising children in the infant room when Child #1, a young toddler, pulled Child #2's hair, also a young toddler. In response, Facility Person #1 lunged at Child #1, picked them up roughly, yelled at them, and put them down aggressively. Facility Person #2 then pulled Child #1's hair. Child #2 was then observed hitting Child #1 and pulling their hair while Facility Person #1 encouraged Child #2 by saying, "It's your turn now," and "Get them back."

**Staff statements and video surveillance footage indicate that on 1/16/24 at approximately 4:00 PM, Facility Persons #1, #2, and #3 were supervising children in the infant room when Child #1, a young toddler, pulled Child #2's hair, also a young toddler. In response, Facility Person #1 lunged at Child #1, picked them up roughly, yelled at them, and put them down aggressively. Facility Person #2 then pulled Child #1's hair. Child #2 was then observed hitting Child #1 and pulling their hair while Facility Person #1 encouraged Child #2 by saying, "It's your turn now," and "Get them back."

Staff statements and video surveillance footage indicate that on 1/16/24 at approximately 4:00 PM, Facility Persons #1, #2, and #3 were supervising children in the infant room when Child #1, a young toddler, pulled Child #2's hair, also a young toddler. In response, Facility Person #1 lunged at Child #1, picked them up roughly, yelled at them, and put them down aggressively. Facility Person #2 then pulled Child #1's hair. Child #2 was then observed hitting Child #1 and pulling their hair while Facility Person #1 encouraged Child #2 by saying, "It's your turn now," and "Get them back."

According to staff statements, there were times when Child #3, a young toddler, was strapped into a chair during naptime, for up to approximately 15 minutes to prevent them from crawling on other children and waking them.

There was an incident report on file for an incident documented as occurring on 12/6/23 and signed by a parent on 12/7/23. There was an incident report on file for an incident documented as occurring on 12/7/23 signed by the parent on 12/13/23. As per staff statements, the incident reports were not given to the parents on the dates of the incidents.

The first aid and CPR training documented and on file for Facility Person #1 was expired as of 7/31/23.

The mandated reporter training documented and on file for Facility Person #2 indicated the training was completed on 6/24/23, more than 90 days after their start date.

SECOND CITATION, CITED PREVIOUSLY ON 6/23/23: On 8/2/23, at approximately 1:35 PM, Facility Person #1 was observed standing in the doorway between the hallway and the South Gym. There were 8 young schoolagers in the gym and one young schoolager in a storage room off the hallway outside of the gym retrieving a piece of equipment. Facility Person #1 was positioned with their back to most of the children in the gym, while they were directing the child in the storage room. There were no other staff present in either the gym or hallway to supervise the children.

**SECOND CITATION, CITED PREVIOUSLY ON 6/23/23: On 8/2/23, at approximately 1:35 PM, Facility Person #1 was observed standing in the doorway between the hallway and the South Gym. There were 8 young schoolagers in the gym and one young schoolager in a storage room off the hallway outside of the gym retrieving a piece of equipment. Facility Person #1 was positioned with their back to most of the children in the gym, while they were directing the child in the storage room. There were no other staff present in either the gym or hallway to supervise the children.

SECOND CITATION, CITED PREVIOUSLY ON 6/23/23: On 8/2/23, at approximately 1:35 PM, Facility Person #1 was observed standing in the doorway between the hallway and the South Gym. There were 8 young schoolagers in the gym and one young schoolager in a storage room off the hallway outside of the gym retrieving a piece of equipment. Facility Person #1 was positioned with their back to most of the children in the gym, while they were directing the child in the storage room. There were no other staff present in either the gym or hallway to supervise the children.

SECOND CITATION, CITED PREVIOUSLY ON 6/23/23: On 8/2/23, at approximately 1:35 PM, Facility Person #1 was observed standing in the doorway between the hallway and the South Gym. There were 8 young schoolagers in the gym and one young schoolager in a storage room off the hallway outside of the gym retrieving a piece of equipment. Facility Person #1 was positioned with their back to most of the children in the gym, while they were directing the child in the storage room. There were no other staff present in either the gym or hallway to supervise the children.

The Schoolage Room has a measured maximum capacity of 18 children. On 7/21/23, there were 25 children observed receiving care in that room at 8:05 AM, and after more children arrived, there were 30 children receiving care in the Schoolage room by 8:15 AM.

According to witness statements, on 5/23/23, at approximately 2:00 PM, Facility Person #1 was the sole staff person supervising 8 preschoolers in the Pre-K room when she left the room, leaving the children unsupervised. According to witness statements it can be determined the children were left unsupervised for a maximum of 10 minutes.

On 6/23/23 at approximately 3:35 PM Facility Person #2 was observed supervising 7 young schoolagers in the North Gym. Facility Person #2 was positioned close to the doorway between the North and South Gyms. There were 6 young schoolagers and 2 older schoolagers in the South Gym without a staff person present in that space. Facility Person #2 indicated she was attempting to supervise both groups of children in the two spaces as Facility Person #3 left for just a few minutes. Within a minute, Facility Person #3 returned to the South Gym.

According to witness statements, on 5/23/23, at approximately 2:00 PM, Facility Person #1 was the sole staff person supervising 8 preschoolers in the Pre-K room when she left the room, leaving the children unsupervised. According to witness statements it can be determined the children were left unsupervised for a maximum of 10 minutes. On 6/23/23 at approximately 3:35 PM Facility Person #2 was observed supervising 7 young schoolagers in the North Gym. Facility Person #2 was positioned close to the doorway between the North and South Gyms. There were 6 young schoolagers and 2 older schoolagers in the South Gym without a staff person present in that space. Facility Person #2 indicated she was attempting to supervise both groups of children in the two spaces as Facility Person #3 left for just a few minutes. Within a minute, Facility Person #3 returned to the South Gym.

According to witness statements, on 5/23/23, at approximately 2:00 PM, Facility Person #1 was the sole staff person supervising 8 preschoolers in the Pre-K room when she left the room, leaving the children unsupervised. According to witness statements it can be determined the children were left unsupervised for a maximum of 10 minutes. On 6/23/23 at approximately 3:35 PM Facility Person #2 was observed supervising 7 young schoolagers in the North Gym. Facility Person #2 was positioned close to the doorway between the North and South Gyms. There were 6 young schoolagers and 2 older schoolagers in the South Gym without a staff person present in that space. Facility Person #2 indicated she was attempting to supervise both groups of children in the two spaces as Facility Person #3 left for just a few minutes. Within a minute, Facility Person #3 returned to the South Gym.

Facility Persons #1 & #2 were observed to be caring for children unsupervised. Facility Person #1 had not completed the following pre-service training required prior to caring for children unsupervised: approved pediatric first aid and CPR; mandated reporter training, health and safety training Facility Person #2 had not completed the following pre-service training required prior to caring for children unsupervised: approved pediatric first aid and CPR

There were two windows open in the North Gym without screens.

The most recent fire drill recorded on the fire drill log was conducted on 3/13/23 -- more than 60 days prior.

The child abuse (3/11/23), criminal history (3/8/23) and FBI (3/8/23) clearances on file for Facility Person #1 were completed after their start date. (See IS code sheet). The child abuse (3/2/23), criminal history (1/20/23) and FBI (1/23/23) clearances on file for Facility Person #4 were completed after their start date. (See IS code sheet). The child abuse clearance (11/11/22) on file for Facility Person #5 was completed after their start date. The criminal history (11/11/22) and NSOR (2/17/23) clearances on file for Facility Person #5 were completed more than 45 days after their start date.(See IS code sheet). The current child abuse and FBI clearances on file for Facility Person #7 were completed more than 60 months after their previous clearances on file.

There was a table with loose legs, causing it to be unsteady, in the Pre-K room.

There were four rest mats used by children in the infant room not labeled with the children's names.

The current health assessments on file for children #2 and #5 were completed more than 12 months after the prior health assessments.

There was no documentation of a current annual flu vaccine on file for children #1-#6. The immunization record on file for child #7 indicates the child did not have sufficient doses of the Hepatitis B, Rotavirus, DTAP, HIB, pneumococcal and polio vaccines as recommended by the ACIP for the child's age.

The health assessment /TB test on file for Facility Person #1 and the TB test on file for Facility Person #5 were completed after their start dates. The current health assessments on file for Facility Persons #7 and #8 were completed more than 24 months after their prior health assessments.

There was no feeding schedule from the parent of an infant in care.

Because the operator is unable to test the facility's smoke detectors and demonstrate operability during the annual inspection, an annual inspection of the detectors is required to be performed by a fire protection professional. The most recent professional inspection documentation on file was dated 3/18/22.

There was no documentation on file that Facility Person #5 has completed the required update to the health and safety training, required to be completed by 12/30/22. The health and safety training documented and on file for Facility Person #6 was completed after 12/30/22.

Facility Persons #2, #3, and #5 were classified as assistant group supervisors without documentation of the required education and/or experience required for the classification on file.

The most recent staff evaluations on file for Facility Person #6, #7 and #8 were completed more than 12 months prior.

The daily activity schedule was not posted in the schoolage room.

There was no copy of a child service report provided to the parent on file for child #5, enrolled more than 6 months The current child service reports on file for children #2 and #6 were completed in January 2023, more than 6 months after the previous child service report on file and after the suspension of the regulation on 10/31/22.

The emergency contact forms and agreements on file for children #2, #5, and #6 were not reviewed and updated in writing by parent within 6 months of previous review.

There was only one written nonfamily reference on file for Facility Person #1.

The DHS contact information was not posted in an area used by the parents of the preschoolers.

At approximately 3:15 PM in the infant room, child #1, an infant, was observed to be sleeping.in a rocker/bouncy seat type of equipment, not in the position recommended by the AAP. There was no medical reason documented by a physician's statement on file for the child to sleep in this position.

According to statements from witness staff, Facility Persons #1 and #2, on multiple occasions, singled out children for ridicule, made degrading comments about children and their family members in the presence of these children and other children, and threatened children in care.

The fire drill log on file indicate fire drills were conducted on 3/8/22, 5/9/22, and 7/25/22 - more than 60 days apart.

They hypothetical locations of the fire drills conducted since 5/9/22 were not recorded on the fire drill log.

The health and safety training completed and on file for Facility Persons #1, #2, #3, and #4 (all employed more than 90 days - see IS Code Sheet) were completed prior to 9/30/16.

There was no documentation of completion of acceptable pediatric first aid and CPR training on file for Facility Person #5, employed at the facility for more than 90 days (See IS Code Sheet).

There was no documentation of current acceptable mandated reporter training on file for Facility Persons #1, #2, and #3, who each have served as lifeguards for the program, when swimming at Camp Sherwin, for more than 90 days.

The NSOR clearance on file for Facility Person #4 was dated after the date of hire (See IS CODE SHEET). The NSOR clearance was dated 3/24/22. The current criminal history clearance on file for Facility Person #7 was dated more than 60 months after the previous criminal history clearance on file. There was no NSOR clearance on file for Facility Persons #8. and #10.

On 4/14/22 at approximately 11:45 AM Facility Persons #1 and #2 were supervising 11 young schoolagers and 3 older schoolagers in the schoolage room. When asked to identify which children they were each supervising, one of the children in care was not identified by either Facility Person #1 or #2.

One of the mattresses in a crib in the infant room was elevated. When asked about infant sleep position, staff stated there is an infant in care who must sleep in an elevated position due to a medical condition. There was no documentation of the medical reason or the need for an alternate sleep position for the infant on file at the facility.

There were sharp adult scissors in a drawer low enough to be in reach of children in the preschool room.

The current emergency plan training documented and on file for Facility Person #8 was completed more than 12 months after the previous emergency plan training documented and on file.

The plan for a lockdown was not included in the letter to the parents providing information about the emergency plan.

There were two spray bottles of cleaners in the infant room and two in the preschool room that were not labeled wit the contents.

There was splintered wood on a panel on the wall near the sink in the back of the kindergarten/schoolage room.

There were two broken plastic bins - creating sharp edges and/or potential pinch points - in the kindergarten/schoolage room.

There was no thermometer in the refrigerator in the kindergarten/schoolage room.

There was no documentation of a current influenza vaccine on file for child #2. There was a written, signed statement from a parent on file indicating a personal objection to the flu vaccine, but the exemption statement was not dated.

The TB test on file for Facility Person #4 was completed more than 12 month's prior to the start date (SEE IS CODE SHEET). The TB test documented and on file for Facility Person #4 was completed on 3/30/18. The current health assessment on file for Facility Person #11 was completed more than 24 months after the prior health assessment on file.

The current health assessment on file for Facility Person #10 did not include an examination for communicable diseases and the results of that examination.

The health assessment on file for Facility Person #10 did not include the physician's or CRNP's assessment of the person's suitability to provide child care.

The menu posted at the facility on 4/14/22 included meals to be served through 4/15/22. The menu for the following week was not posted.

There was no proof of purchase for the interconnected fire alarm system on file at the facility.

There was no health assessment on file for child #5, enrolled at the facility more than 60 days.

The certificate of compliance posted a the facility was expired.

The current pediatric first aid/CPR training on file for Facility Persons #7 #9 and #11 were not completed prior to the expiration of their previous certification.

The only firesafety training completed and documented on file for Facility Person #8 was completed more than 12 months after the start date. (SEE IS CODE SHEET). The firesafety training completed by Facility Person #8 was completed 3/25/22.

There was no documentation of required pre-service health and safety training documented and on file for Facility Persons #5 and #10, both employed more than 90 days at the facility. (See IS CODE SHEET).

The current staff evaluations completed and on file for Facility Persons #3. #7, #8, #9, #10 and #11 were completed more than 12 months after the prior staff evaluations on file.

On 4/14/22, there were schoolage children in care in the kindergarten/schoolage room throughout the day, including typical school hours as child care was provided during a planned school closure. The posted daily schedule in the classroom reflected only after-school hours and activities.There was no full day schedule posted.

Several of the release persons listed on the agreements on file for children #1-#5 were not also listed on the emergency contact form on file, or were listed without an address and/or phone number.

There was only one written nonfamily reference on file for Facility Person #5.

There was no documentation of completion of pediatric first aid/CPR on file for Facility Person #4, employed at the facility more than 90 days.(SEE IS CODE SHEET). The pediatric first aid/CPR documented and on file for Facility Person #6 was complete more than 90 days after the start date. (SEE IS CODE SHEET). The pediatric first aid/CPR documented an on file for Facility Person #6 was completed on 4/5/22.

There were less than 12 hours of child care training completed within the most recent complete review year and documented and on file for Facility Persons #3, #7, #8, #9, #10, and #11.