Elizabeth Seton Center-Childrens Program

During a complaint investigation conducted on 8/5/25, based on information obtained during staff interviews, it was determined that Staff #1 singled out and expressed a negative attitude towards a specific child in front of other children and staff. On July 30th, when Staff #1 had been given the option to supervise children on a swim outing, Staff person #1 was overheard saying that 'if Child #1 is not going to swim, I will go swimming but if Child #1 is going swimming I do not want to go'. Staff person #1 has also been heard saying things such as, 'have fun with Child #1' or 'watch out for Child #1'. During transition times, Staff person #1 has been heard saying that they 'do not want to deal with Child #1 so [Child #1] can stay in the room'.

The file for Staff person #1 includes an incomplete criminal history clearance that did not include a dissemination date, (See LIS Code Sheet), making it invalid; the previous Criminal History clearance is dated 5.8.19, more than 60 months ago. The file for Staff person #1 includes an FBI clearance dated 5.21.19, more than 60 months ago and also included an FBI clearance obtained through the PA Department of Education, dated 7.31.24, which is not valid for employment in a childcare facility.

During an unannounced monitoring visit at a swimming activity, it was observed that the LE had children and staff from 2 separate locations at the pool, with only one lifeguard present, supervising swimming activity for 2 locations simultaneously.

The file for Staff person #1 does not include verification of emergency plan training completed within 90 days of hire (See LIS Code Sheet).

According to staff statements, children apply sunscreen at the facility prior to going to the pool, but some children take sunscreen to the pool and keep it in their possession, making it accessible to children in care.

Staff person #1 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet).

According to staff statements, on 4.30.25, the front door was propped open for a portion of the day when there was a power outage, due to the security system not working. It was observed, however, that there is no screen on the door that was open for several hours.

According to staff statements, on 4.30.25, the facility telephone system was not functioning for a portion of the day when there was a power outage.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR; the training was completed on 2.18.25.

Staff person #2 completed current mandated reporter training on 4.9.25, more than 60 months after the previous training dated 3.14.20. Staff person #3 completed current mandated reporter training on 4.10.25, more than 60 months after the previous training dated 3.16.20. Staff person #4 has not completed mandated reporter training within the last 60 months; the previously documented mandated reporter training on file is dated 3.13.20.

The file for Staff #2 (see IS Code Sheet) contained a State Police Clearance dated 7.29.24, with no application available, which was after the first date caring for children. The file for Staff #3 (see IS Code Sheet), contained a State Police Clearance dated 11.14.24, with no application available, which was after the first date caring for children. The file for Staff #4 contained Child Abuse Clearances dated 11.1.19 and 11.4.24, which exceeded 60 months. The file for Staff #6 contained FBI Clearances dated 8.7.15 and 9.14.20, which exceeded 60 months. The file for Staff #7 contained FBI Clearances dated 8.7.15 and 10.11.20, which exceeded 60 months. The file for Staff #11 contained FBI Clearances dated 10.6.15 and 10.15.20, with an application dated 10.12.20, which exceeded 60 months. The file for Staff #14 (see IS Code Sheet) contained a Child Abuse Clearance dated 11.28.23, which was after the first date caring for children. The file for Staff #16 contained FBI Clearances dated 8.7.15 and 8.19.20, with no application available, which exceeded 60 months. The file for Staff #17 (see IS Code Sheet) contained documentation of Mandated Reporter training dated 8.23.20, which exceeded…

The file for Staff #26 contained documentation of Emergency Plan training on 5.17.23 and 10.1.24, which exceeded 12 months. The file for Staff #28 contained documentation of Emergency Plan training on 9.26.23 and 10.9.24, which exceeded 12 months.

As confirmed by the operator, a Parent Letter was not provided to explain the emergency procedures.

The file for Child #9 contained documentation of a Health Assessment on 5.19.23, and none thereafter, which is required at least every 12 months.

The two (2) most recent Health Assessments in the file for Staff #1, Staff #6, Staff #9, Staff #11, Staff #18, Staff #30, and Staff #34 exceeded the 24-month renewal requirement.

The file for Staff #21 did not contain documentation of the Health and Safety 1-Hour Update training.

The file for Staff #1, Staff #5, Staff #6, Staff #7, Staff #8, Staff #9, Staff #10, Staff #11, Staff #12, Staff #15, Staff #16, Staff #17, Staff #18, Staff #19, Staff #20, Staff #22, Staff #24, Staff #25, Staff #27, Staff #29, Staff #30, Staff #31, Staff #32, Staff #33, Staff #34, and Staff #35 contained Pediatric First-Aid/CPR training which expired on 11.2.23, and it was not renewed until 11.7.23.

The file for Staff #13 contained documentation of Fire Safety training on 5.16.23 and 11.13.24, which exceeded 12 months. The file for Staff #14 contained documentation of Fire Safety training on 10.4.23 and 11.7.24, which exceeded 12 months. The file for Staff #21 contained documentation of Fire Safety training on 5.16.23 and 11.13.24, which exceeded 12 months. The file for Staff #23 contained documentation of Fire Safety training on 2.11.23 and 11.7.24, which exceeded 12 months. The file for Staff #26 (see IS Code Sheet) contained documentation of Fire Safety training on 9.10.24, which exceeded 12 months from date of hire. The file for Staff #27 contained documentation of Fire Safety training on 11.7.23 and none thereafter, which exceeded 12 months. The file for Staff #36 contained documentation of Fire Safety training on 2.11.23 and 11.11.24, which exceeded 12 months.

The files for Child #8 and Child #9 did not contain Child Service Reports every 6 months.

The Agreements in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10 did not specify the child's arrival and departure times.

The Agreements in the files for Child #5 and Child #9 did not specify the date of the child's admission.

In Room 5 and Room 11, an Emergency Transportation Plan was not displayed.

The file for Child #8 did not contain documentation that the Emergency Contact Form and Agreement were reviewed/updated at least every six (6) months.

The file for Staff #21 (see IS Code Sheet) contained documentation of Health & Safety training 10-hour, on 10.31.22, which exceeded 90 days of hire. The file for Staff #31 (see IS Code Sheet) contained documentation of Health & Safety training 10-hour, on 5.7.21, which exceeded 90 days of hire.

The file for Staff #21 (see IS Code Sheet) contained documentation of Pediatric First-Aid/CPR training on 5.16.23, which exceeded 90 days of hire. The file for Staff #23 (see IS Code Sheet) contained documentation of Pediatric First-Aid/CPR training on 2.11.23, which exceeded 90 days of hire. The file for Staff #28 (see IS Code Sheet) contained documentation of Pediatric First-Aid/CPR training on 11.7.23, which exceeded 90 days of hire.

The fire alarm 30-day test log includes test dates 1/30/24-3/1/24, more than 30 days apart.

The file for staff #7 indicates that staff #7 was improperly provisionally hired. The NSOR was requested 4 days late (9/21/23) after staff #7 started.

The file for staff #8 lacks a valid NSOR certificate.

The files for staff #3, #4, #6, #11 contain clearances that were obtained or updated late. #3 - FBI obtained 9/2023 and due 7/2023; #4 - state police obtained 9/2023 and due 5/2023, child abuse obtained 9/2023 and due 5/2023, FBI obtained 9/2023 and due 12/2022; #6 - NSOR obtained 2/22/23 and due 2/13/23; #11 - state police obtained 9/2023 and due 8/2023.

The file for staff #9 contains emergency plan training that was obtained late. The training was due 2/2023 and obtained 9/2023.

Observed several damaged areas on the playground surfacing in the school aged playground.

Observed several damaged playground toys on the school age playground.

The files for staff #7, #8, #13, #14, #15, and #17 contain health assessments that were initially obtained or renewed late. #7 due 9/16/23 and obtained 9/26/23; #8 due 11/7/22 and obtained 11/30/22; #13 due 10/5/23 and obtained 10/6/23; #14 due 6/2023 and obtained 9/2023; #15 due 1/2023 and obtained 2/2023; #17 due 3/2023 and obtained 9/2023.

The file for staff #5 lacks a valid health assessment. The health assessment on file exceeded 12 months old at the time of hire. It was 14 months old.

The files for staff #7 and #8 contain late TB tests. #7 due 9/16 23 and obtained 9/24/23; #8 due 11/7/22 and obtained 11/30/22.

The files for staff #5 and #9 lack current TB testing. The TB test on file for staff #5 was 14 months old rather than 12 months and the TB test on file for staff #9 was from 2007 when staff was an employee at the facility in the past.

Staffs persons #8 and #18 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): #8 - first aid and cpr and health and safety training; #18 - health and safety update.

The files for staff #9, #10, #12, #16, and #19 contain health and safety trainings that were obtained late. #9 - FA/CPR due 1/29/23 and obtained 2/11/23, mandated reporter training due 1/29/22 and obtained 10/5/23; #10 FA/CPR and mandated reporter due 7/2023 and obtained 10/2023; #12 health and safety update training due 12/2022 and obtained 10/2023; #16 health and safety update training due 12/2022 and obtained 11/2023;

The files for staff #4 and #9 contain mandated reporter training that was obtained/updated late. #4 due 5/2023 and obtained 9/2023; #9 due 1/29/23 and obtained 10/5/23.

The files for staff #1 and #2 lack 12 hours of annual child care training for the 12/2021 to 12/2022 time period. Both staff completed part of their 12 hours late (after 12/2022) and are both still in need of 1.5 hours of annual child care training hours.

The file for staff #1 contains a criminal clearance that was obtained late. The operator indicates that a timely clearance was obtained prior to employment but could not be located at a later time. The clearance that is now on file is acceptable.

The facility has not sent a copy of the most recent emergency plan to the local municipality and to the county emergency management agency.

Staff #2 has not completed the mandated reporter training within the 90 days of their date of hire (see LIS code sheet).

Staff #1 and #3 had not completed the following required pre-service training within the 90 days of their date of hire (see LIS code sheet). The file for staff #1 contained a mandated reporter training dated 10/12/22, which was greater than 90 days after their date of hire (see LIS code sheet). The file for staff #3 contained a mandated reporter training dated 10/11/22, which was greater than 90 days after their date of hire (see LIS code sheet).

The file for staff #4 lacks verification of an education (high school diploma). The diploma that is on file needs to be interpretted since it is in another language other than English.

The file for staff #1 lacks verification of the NSOR clearance. Staff #1 was observed providing lifeguarding duties for children at the pool on 7/20/22 under the supervision of other staff with valid NSOR clearances. Staff #1 was not provisionally hired.

The file for staff #1 lacks a current health assessment.

The file for staff #1 lacks a current TB test.

The file for staff #16 did not contain a valid state police clearance. The clearance on file lacked the date it was disseminated from the system. The date requested was 10/5/18. The file for staff #30, with a start date of 12/29/07, did not contain a completed NSOR certificate. Staff #16 and #30 may not work in a child care position at the facility.

The file for staff #37 did not contain documentation of current emergency plan training. The most recent training on file was dated 9/06/19.

The following toxics were observed to be accessible to children on 10/22/21; Lysol in an unlocked storage room in the outdoor play space and hand sanitizer in a cabinet drawer in the hallway on the lower level.

The water temperature in the 2 sinks in the school age restroom at the end of the hall measured 118° F on 10/22/21.

Protruding sharp wires were observed on the bottom of the gate and fence of the outdoor toddler play area.

A highchair cover in the young toddler room was cracked with the inner foam filling exposed and accessible. A broken Styrofoam cup was observed in the toddler outdoor play space.

The files for staff #13, #18, #22, #24, and #26 contained health assessments which were not updated within 24 months as required. The most recent health assessments on file for these staff are now current. The files for staff #25 and #29 did not contain current health assessments.

Based on documentation at the facility, the following staff members did not participate in fire safety training annually as required. Training was completed in October 2020 and again on 11/2/21; Staff #1 -5, #8 -13, #15, #16, #18 - 26, and #30 - 36. The files for these staff members now contain documentation of current fire safety training. The files for staff #29 and #37 do not contain documentation of current fire safety training. The most recent training on file for both staff occurred 11/5/19.

The file for staff #27 contained documentation of receiving Pediatric CPR and first aid training more than 90 days after their start date of 5/26/21. The files for the following staff, hired prior to 12/19/20, contained documentation of receiving Pediatric CPR and First Aid after the deadline of 6/17/21; #7 -11, #17, #19, #23, #25, #28, #35, and #36. Staff received the training on 11/02/21.

The files for staff #14, #16, #24, all employed for over 90 days, did not contain documentation of completing health and safety training topics 1 through 9 as described in 3270.31f.

Based on documentation at the facility, staff #15 and #30 did not update mandated reporter training within 60 months as required. Staff #15 previously completed the training on 8/08/16 and updated it on 9/21/21. Staff #30 previously completed the training on 4/7/15. The updated training completed by staff #30 on 8/28/21 was not from an approved source. Based on documentation, staff #17 did not complete mandated reporter training within 90 days of hire as required. Staff #17 was hired on 11/02/20 and completed the training on 10/26/21. Both staff #15 and #17 now have documentation of current training on file.

The files for staff #22, #26, #29, and #37 did not contain written evaluations completed within the last 12 months.

The operator did not provide parents with information on how to access the regulations in this chapter electronically and did not provide them with instructions for contacting the appropriate regional child care office.