Eps Pennbriar Child Care LLC

The most recent NSOR Certificates in the files for Staff Person #4 and #8 exceeded 60 months between certificates.

Observed in the following areas: Tiny Tots Room: Sections of overhang that had fallen from the outside were laying on the play pool table. Ones Room: Hinges are becoming detached, and wood is bowed on the closet doors upon entrance to the room, which creates a pinch hazard between the doors. Twos/PS Room: Hole in the wall behind the first toilet in bathroom where the water pipe connects. Infant Room: Holes in the wall where the diaper shelf had been removed. Gym: Holes in the wall on the right side of the right wall next to the blue wall mat, corner molding by pump room separating from the wall. Broken and missing ceiling tiles above both racquetball courts.

Observed dirt and debris under the mat and in the compartments of the diaper changing table in the Twos/PS Room. Padding was torn on the basketball set on the left side of the gym.

The most recent immunization record in the file for Child #3 did not include two Hep A immunizations or a letter of exemption from the parent or physician.

Observed a bottle of Tylenol in the medication box that was not labeled with the name of Child #2 for whom the medication was intended.

The most recent health assessments in the files for Staff Person #3, 5, 6 and 7 exceeded 24 months between assessments.

The most current health assessment in the file for Staff Person #8 did not include an examination for communicable diseases and the results of that examination or the physician's or CRNP's assessment of the person's suitability to provide child care.

The most current health assessment in the file for Staff Person #2 states that the individual is not suitable for child care and requires clearance from PCP due to physical limitations.

The initial health report in the file for Child #5 was conducted more than 60 days after the child's first day in care.

The most recent Pediatric First Aid/CPR Certification in an approved curriculum from an approved PQAS Instructor in the file for Staff Person #6 is expired.

The files for Staff Person #9 and #11 did not include documentation of firesafety training conducted within the past 12 months.

The Mandated Reporter Training in the file for Staff Person #1 was conducted more than 90 days after the staff person's first day working in child care. The most recent Mandated Reporter Trainings in the file for Staff Person #10 exceeded 60 months between trainings.

The daily activity schedules were not posted in the Infant and PS Rooms.

The emergency contact forms in the files for Child #3 and #4 lacked the release persons' addresses.

The emergency contact binder in the Ones Room lacked an emergency contact form for Child #1, who was receiving care in this space.

The Emergency Transportation Plan was not posted in the Infant and PS Rooms.

The first parental updates for the emergency contact form and fee agreement in the file for Child #5 were conducted more than 6 months after the child's first day of attendance.

Staff person #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 7/8/19.

The most recent FBI clearances in the file for Staff Person #6 exceeded 60 months between clearances.

The facility's emergency plan did not include requirements for volunteer emergency preparedness training, practice drills and continuity of operations (backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster) to maintain compliance with 45 CFR § 98.41(a)(1)(vii).

The Toddler Back Room lacked a first aid kit.

The first aid kit in the excursion bag for the 2's/3's Preschool Room lacked tweezers and gloves.

Observed an exposed bolt protruding from the cap of a drain cover in the Tiny Tots Room. Observed rust on the bottom of the partitions between the toilet stalls in the restroom between the Toddlers Rear and 2's/3's PS Rooms. Observed an outlet box separating from the wall in the 2's/3's PS Room. Observed a loose screw on the power strip mounting in the Infant Room. Observed two ceiling tiles discolored from water damage in the Pre-K Room.

The exit door to the hallway of the Pre-K Room was blocked by a toy shelf. The door between the two rear portions of the Pre-K Room was blocked by chairs and rest mats.

The metal connectors securing the frame of the playset in the PS/SA Playground were protruding. Observed several cracks, which create sharp edges, in the roof of the playhouse in the Infant/Toddler Playground. Observed dirt and debris under the diaper changing mat in the 2's'PS Room.

Observed teeth marks in the foam blocks in Tiny Tots Room and the Pre-K Room. Observed a plastic baggy on the table of the 2's/PS Room. This creates a potential choking hazard to children who may still be placing objects in their mouths.

The refrigerator in the 2's/3's Preschool Room lacked a thermometer.

The most recent health reports in the file for Child #1, a young toddler, exceeded six months between reports.

The file for Child #3, an older toddler, did not include an updated health report conducted within the past 12 months.

The most recent health report in the file for Child #1 did not include an immunization record or a letter of exemption from the parent or physician.

The most recent health report in the file for Child #5 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

An annual emergency drill had not been documented within the past 12 months.

The fire drill/fire detection log documented one time when monthly fire system checks exceeded 30 days between checks: 3/15/24-4/15/24.

The initial health report in the file for Child #2 was conducted more than 60 days after the child's first day of attendance at the facility.

The files for Staff Persons #1, 2, 3, 4, 5, 6, 7, 9 and 10 did not include documentation of annual fire safety training conducted within the past 12 months.

The most recent annual evaluations in the files for Staff Persons #1, 3, 4, 5, 6, 7 and 10 exceeded 12 months between evaluations. The first annual evaluations in the files for Staff Persons #8, 9 and 11 were conducted more than 12 months after the staff persons' first day working in child care (See LIS Code Sheet).

The fee agreement in the file for Child #2 did not specify the date on which the fee is to be paid and the date of the child's admission.

The most recent child service reports in the files for Child #1, 2 and 3 were dated more than six months after the child's first day in child care. The file for Child #4, who has been enrolled for more than six months, did not include a child service report.

The emergency contact form in the file for Child #6 did not include the work address and telephone number of the enrolling parent. The emergency contact form in the file for Child #7 did not include the work telephone number of the enrolling parent.

The emergency contact form in the file for Child #6 did not include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

The emergency contact forms in the files for Child #1 through Child #7 did not include the addresses of the release persons.

The most recent parent updates for the emergency plans and fee agreements in the file for Child #1, 3, 4, 6 and 7 were updated more than six months after the child's first day in care. The emergency contact form and fee agreement in the file for Child #2, who has been enrolled for more than 6 months, have not been updated by the parent.

The file for Staff Person #2 contained documentation of 9 annual hours of child care training for the most recent year of childcare. The file for Staff Person #5 contained documentation of 10 annual hours of child care training for the most recent year of childcare.

Based on an interview with Staff Person #1, it was determined the original incident report, for an incident dated January 25, 2024, was not given to the parent the day of the incident. The incident report was signed and dated by the parent: January 26, 2024.

* Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

* * * * Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

* * * Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

* * Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

* Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

* * Previously cited on 11/9/23 SIN-00233634. During correction verification visit on 1/30/24 at 3:45 PM, Cert Rep observed four School Age children open the door of the van from the inside, exit the vehicle and walk up the steps to let themselves into the facility. The children were not supervised by a staff person from the time they exited the vehicle until the time they entered the facility. The driver, Staff Person #2, remained in the vehicle for an additional five minutes before entering the facility.

Staff person #1 was observed to be caring for children unsupervised. Staff person #1 has not completed the following pre-service training required prior to caring for children unsupervised: Pediatric First Aid and CPR.

Staff person #1, a provisional hire was observed working alone with children unsupervised in the preschool room with 5 preschool children and 2 older toddlers.

During naptime, upon entry to the preschool room and the young toddler room, there was not sufficient lighting for staff to see the children who were napping on their cots.

*Through staff interviews it is verified that child #1, a young toddler, fell approximately halfway down an unrestricted flight of stairs while in the supervision group of staff person #1. Child #1 was not being adequately supervised to prevent his/her access to the stairs.

**Through staff interviews it is verified that child #1, a young toddler, fell approximately halfway down an unrestricted flight of stairs while in the supervision group of staff person #1. Child #1 was not being adequately supervised to prevent his/her access to the stairs.

Through staff interviews it is verified that child #1, a young toddler, fell approximately halfway down an unrestricted flight of stairs while in the supervision group of staff person #1. Staff person #1 was not aware of the whereabouts of Child #1 which allowed for his/her access to the stairs.

Observed the stairway located in the center of the Main Floor child care space was lacking a barrier to the stairwell allowing a young toddler receiving care in the child care space to access the stairs.

Based on conversations with Director and Staff, it is verified that Staff Person #1 and Staff Person #2, the drivers employed by the facility, drop off younger and older school-age children from the second school pickup run daily. Then the drivers do not exit the vehicle and walk the children up the steps to the facility after this second run and no staff person escort the children into the facility. The children are allowed to enter the entry code to let themselves into the facility. Additionally, the children are not assigned to a staff person from the time they exit the van until the time a staff person meets them inside which leads directly into the Main School Age Room where a staff person is waiting.

The file for staff person #1, hire date (see LIS code sheet) contains FBI clearance that expired 7/17/2023 and contains documentation of fingerprinting on 10/21/2023 but is lacking a valid completed FBI clearance. The files for staff persons #2,#4,#5,#6,#7 and #8 contain disclosure statements that are not the current from and therefore not valid. The file for staff person #4, hire date (see LIS code sheet), is lacking a child abuse clearance at the time of initial hire as required under CPSL. The clearance is now complete.

Observed on 11/9/2023 at ~9:05am Staff person #9 supervising 12 YSA and 6 PS children alone in the main child care space until ~9:15 when another staff person arrived.

Based on conversations with Director and Staff, it is verified that Staff Person #1 and Staff Person #2, the drivers employed by the facility, drop off younger and older school-age children from the second school pickup run daily. Then the drivers do not exit the vehicle and walk the children up the steps to the facility after this second run and no staff person escort the children into the facility. The children are allowed to enter the entry code to let themselves into the facility. Additionally, the children are not assigned to a staff person from the time they exit the van until the time a staff person meets them inside which leads directly into the Main School Age Room where a staff person is waiting.

The parent letter regarding the facility emergency plan has not been updated and does not include the facility's plan for a lockdown and does not include the facility's plans for accommodations for infants, toddlers and children with special needs during an emergency.

Observed in the back toddler room, which was not in use on the day of inspection, mouse droppings on the countertop in the kitchenette area.

Observed in the back toddler room a toy grocery check-out shelf with exposed screws. Observed in the preschool room a plastic bin labeled for 'music' on the toy shelf was cracked with a sharp edge.

The rest cots in the pre-k room were not labeled with the children's names for individual use.

The file for child #3, preschool aged, is lacking a health report during the previous 12 month period.

Observed in the infant room a bottle of Midol and observed in the front toddler room a bottle of children's Motrin, both lacking the name of the person for whom they were intended.

Observed in the infant room a bottle of Midol and observed in the front toddler room a bottle of children's Motrin, both lacking parent's written consent for administration.

The file for staff person #3 contains a current health assessment that was completed greater than 24 months after the previous health assessment. The file is now current. The file for staff person #7 is lacking an initial health report.

The file for staff person #7 is lacking the results of a TB test.

The file for child #6 contains an initial health report that was conducted greater than 60 days after the first date of attendance. The file is now current. The file for child #4, school aged, is lacking an initial health report and has been in attendance greater than 60 days.

The facility is lacking a policy regarding shaken baby syndrome, abusing head trauma and child maltreatment.

The file for staff person #1 contains PFA/CPR certification that expired 8/26/2023 and contains updated training that was not completed by a PQAS certified trainer.

Staff person #7 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): PFA/PCPR by a PQAS certified trainer.

The file for staff person #2, serving as AGS, is lacking verification of a high school diploma or GED to qualify as an AGS. The file for staff person #6, serving as an AGS, contains documentation of verification of hours that does not specify that the experience was caring for children. Staff #2 and #6 may only serve as aides.

There was not a written daily schedule posted in the back toddler room.

The files for child #4 and #5 contain financial agreements that are missing a date on which the fee is to be paid.

The files for child #1,#2 and #3 are lacking child service reports completed during the previous 6 month period.

The files for child #1, #5 and #6 contain current emergency contact and financial agreements that were updated greater than 6 months after the previous update. The file for child #3 has not been updated in the previous 6 month period.

The file for staff person #7 is lacking two written non-family reference letters.

The file for staff person #5, hire date (see LIS code sheet), contains valid PFA/PCPR training completed greater than 90 days after hire date. The training is now current.

Upon review of the facility's 30-day fire testing documentation, the following tests were observed to have been conducted more than 30 days apart: 7/14/23 - 8/24/23 (41days), 9/15/23 - 10/26/23 (41 days).

According to staff interview, staff #1 used physical discipline with child #1 when they grabbed the child's arm leaving marks.

Staff person #1 was observed to be caring for children unsupervised. Staff person #1 has not completed the following pre-service training required prior to caring for children unsupervised: PFA/PCPR

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): PFA/PCPR

On 1/23/2023 at approximately 11:00am staff person #5 named 7 children in her supervision group however was only able to locate 6 of the children. The location of child #5, young school age, remained unknown for approximately 5 minutes at which time she emerged from a classroom metal locker where she had been hiding.

The water at the sink in the Pre-K room was 125 degrees and accessible to children in care.

Observed a crack at the bottom of the kitchen door posing a sharp edge accessible to children. Observed 4 protruding exposed bolts on the fence post near the gate to the larger playground.

Observed in the Preschool - 2's, 3's room a plastic toy shopping cart that was visibly soiled.

Observed in the Preschool - 2's, 3's room a small, approximately 1/2 inch screw laying on the floor next to a shelf and accessible to the 2 and 3 year olds in care.

Observed in the Preschool - 2's, 3's room a toy shelf with a splintering strip of wood on the edge causing a potential hazard to the children in care.

The file for child #1, a young toddler, is lacking an updated health assessment in the previous 6 month period.

The file for child #3, preschool age, is a lacking an updated health report conducted during the previous 12 month period.

The file for child #2, preschool age, contains a health report that is lacking an immunization report and has been attending for greater than 60 days.

The file for child #1, young toddler, is lacking current HepB, DTAP,Hib,pneumococcal, polio, MMR, varicella and influenza vaccinations. The files for child #3 and #4, preschool aged, are lacking flu shots during the previous year.

The files for staff persons #1,#2,#3 and #4 are lacking current health assessments.

The legal entity did not provide verification of liability insurance.

The files for child #1 and #3 are lacking current health reports and updated immunization reports. The file for child #2 is lacking an immunization report. The file for child #4 is lacking a flu shot in the previous year.