Good Shepherd Evangelical Lutheran Church

During a swimming inspection on 7/30/25 the following violations of the CPSL were noted: Facility Person 1 did not have an NSOR certificate. Staff 4's FBI clearance was dated 6/11/25 which is after their first day with children. There was no FBI request documented in the file. Staff 4's disclosure statement was dated 7/7/25 which is after their first day with children. Staff 4 was provisionally hired. See LIS code sheet for first day with children.

During a swimming inspection on 7/30/25 Facility person 2, and Staff 3 did not have a disclosure statement that was signed by the staff and a witness and dated. Facility person 2, and Staff 3 were not hired provisionally. See LIS code sheet for first day with children.

During a swimming inspection on 7/30/25 Each staff had a first aid kit for their care group. Cert rep observed no first aid kit's present on the excursion to the pool had all of the required items: Staff 6's first aid kit did not have soap, tape, scissors, and a bottle of water. Staff 7's first aid kit did not have soap, an assortment of adhesive bandages, scissors, gloves and a bottle of water. The remaining first aid kits did not have soap, sterile gauze pads, tweezers, tape, scissors a bottle of water.

During a swimming inspection on 7/30/25 Staff 3's health assessment was dated 6/10/25, which is after their first day with children. See LIS code sheet for 1st day with children.

During a swimming inspection on 7/30/25 Staff 5 and 6 did not have staff evaluations in their staff files. Director reported that staff evaluations were not being completed for seasonal staff.

During a swimming inspection on 7/30/25 Child 1's record did not contain signed parental consent for the administration of minor first aid by facility persons.

During a swimming inspection on 7/30/25 Staff 3 did not have verification of education or childcare experience in their staff file. It was reported Staff 3 worked at a local school and graduated high school.

During a swimming inspection on 7/30/25 Staff 3 and 4 did not have two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

During a renewal inspection on 4/23/25 Cert rep noted Staff 2 had PSP clearances dated 11/6/19 and 3/28/25, Child abuse clearances dated 11/13/19 and 4/3/25, and FBI clearances dated 11/8/19 and 3/31/25. These time frames are more than 60 months between the clearances. The director confirmed Staff 2 continued to work in a childcare position between 11/6/24-and 4/3/25.

During a renewal inspection on 4/23/25 Cert rep observed Staff 4 had 13 young school aged children in her assigned group. It was reported that Staff 1 originally had a group of 6 young school aged children, and Staff 4 had a group of 7 young school aged children. Staff 1 gave 5 of her children to Staff 4(resulting in Staff 4 having 12 children) so that Staff 1 could take 1 child to the bathroom. When Staff 1 returned, she gave her last child to Staff 4(resulting in Staff 4 having 13 children) so that Staff 2 could complete clean up tasks.

During a renewal inspection on 4/23/25 Cert rep noted Child 4's DHS Health assessment form did not have an answer to the if child is able to participate in child care and appears to be free from contagious or communicable disease and if age-appropriate screenings recommended by the American Academy of Pediatrics.

During a renewal inspection on 4/23/25 Staff 1's health assessments were dated 1/8/23 and 2/12/25, Staff 2's were dated 3/29/22 and 4/3/24, and Staff 3's were dated 10/28/22 and 11/16/24. These time frames are more than 24 months. It was reported that these staff worked in childcare positions after the expiration of their previous health assessments.

During a renewal inspection on 4/23/25 Cert rep noted Emergency drills took place on 3/11/24 and 4/11/25, which is more than 12 months between emergency drills.

During a renewal inspection on 4/23/25 Cert rep noted more than 60 days between fire drills on one occasion(11/13/24-1/13/25).

During a renewal inspection on 4/23/25 Cert rep observed Expo cleaner, dish soap, and Lysol cleaner on an accessible shelf in an unlocked closest in the Centers Room, and Lysol spray and Mr. Clean Cleaner on an accessible shelf in the hallway on the way to the Game Room. All of these items were labeled "keep out of reach of children".

During a renewal inspection on 4/23/25 Cert rep noted the facility's emergency plan did not address continuity of operations. Cert rep also noted the facility did not have a written policy to address the following: recognition of potential signs/symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child and the prevention and identification of child maltreatment

During a renewal inspection on 4/23/25 Cert rep noted Staff 2 had mandated reporter training dated 2/19/20 and 4/1/25 which is more than 60 months between trainings.

During a renewal inspection on 4/23/25 Cert rep noted parent were not being provided information regarding Supervision policies and health policies in writing at the time of enrollment.

During a renewal inspection on 4/23/25 Cert rep noted Child 1's emergency contact form did not have the physician phone number and Child 2's form did not have the physician address.

During a renewal inspection on 4/23/25 Cert rep noted Children 1, 2, 3, and 4's emergency contact form did not have the parent's work address, and Child 3's form did not have the parents work phone number. Child 4's emergency contact form did not have addresses for the release persons.

During an unannounced inspection on 10/30/24 Fire detection testing log was reviewed and had one incident of more than 30 days between testing: 9/6/24-10/30/24.

On 4/25/2024, Staff #3 did not have the required DHS FBI clearance on file. The most recent DHS FBI clearance on file was dated 9/11/2018. Staff #3 had an unofficial clearance from the Department of Education.

On 4/25/2024, both Staff #1 and #2 had current health assessments on file. However, the current health assessment for Staff #1 was dated 1/12/2024, while the previous health assessment that was on file for Staff #1 was dated 9/3/2021. The current health assessment for Staff #2 was dated 9/18/2023, while the previous health assessment that was on file for Staff #2 was dated 8/13/2021.

On 4/25/2024, Child #1 did not have an initial health report on file. See LIS code sheet.

On 4/20/2023, Staff #8 and Staff #9 had current clearances on file. However, the clearances were renewed as follows for Staff # 8: State police on 3/22/2023, child abuse on 3/27/2023 and the FBI on 4/4/2023. The previous clearances on file for Staff #8 were dated 1/1/2018 for the state police and child abuse and 1/12/2018 for the FBI. The current FBI clearance for Staff #9 was dated 4/4/2023. The previous FBI clearance on file for Staff #9 was dated 10/5/2017.

On 4/20/2023, the most recent health assessment on file for Staff #2 was dated 4/2/2021. See LIS code sheet. Staff #7 had updated health on file dated 1/8/2023, but the prior health assessment on file for Staff #7 was dated 9/2/2020.

Staff #3, #4, #5, #6, #7, #8, #9 and #10 did not complete the required one-hour 2022 update to the health and safety training by 12/30/2022.

Staff #9 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 3/11/2018.

Staff #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Professional development in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR)

An unannounced inspection was conducted on 7/12/2022. The following was observed during the review of staff files: Facility Person/Staff #1 had an FBI clearance that was more than 60 months old (6/12/2017) on file, a volunteer state police clearance and did not have the National Sex Offender Registry (NSOR) clearance or request on file. Facility Person/Staff #2 did not have the FBI clearance or request on file and did not have the completed National Sex Offender Registry (NSOR) clearance on file. Facility Person #3, a volunteer did not have the clearances or requests on file for the FBI, child abuse, and National Sex Offender Registry (NSOR). Facility Person #4, a volunteer did not have the clearances or requests on file for the FBI or the National Sex Offender Registry (NSOR). Facility Person #5, a volunteer did not have the clearances or requests on file for the FBI, child abuse, and National Sex Offender Registry (NSOR). See LIS code sheet.

The operator disclosed that they have taken the children swimming this summer. The facility does not have anybody on staff that is certified in lifeguard training.

The operator disclosed that they have taken the children swimming this summer. The facility does not have any staff that have completed annual water safety training.

An unannounced inspection was conducted on 7/12/2022. It was verified through staff interviews that while on an excursion away from the facility on 6/30/2022 that the diabetic lancet used by a child was not disposed of properly. The lancet was placed in a plastic bag that was then placed into a trash can.

The operator confirmed that a child at the facility is prescribed insulin while in care this summer beginning in June 2022. The operator did not have parental consent for administering this medication and also did not have a medication log established until 7/11/2022.

An unannounced inspection was conducted on 7/12/2022. Facility Person/Staff #1 had a tuberculosis screening by the Mantoux method within the previous 12 months of starting employment on file, but not have a completed health assessment on file. Facility Person/Staff #2 did not have a completed health assessment and tuberculosis screening by the Mantoux method within the previous 12 months of starting employment on file. Facility Person #3, #4 and #5, all volunteers did not have completed health assessments and tuberculosis screenings by the Mantoux method on file. Facility Person/Staff #6 and #7 both had tuberculosis screenings by the Mantoux method conducted within the previous 12 months prior to beginning employment on file, but Facility Person/Staff #6 and #7 did not complete health assessments on file. Facility Person/Staff #8 did not have a health assessment and tuberculosis screening by the Mantoux method on file. See LIS code sheet.

During an unannounced inspection on 7/12/2022, Facility Persons #1, #2, #3, #4, #5, #6, #7 and #8 did not have two written, nonfamily references on file. See LIS code sheet.

During the Renewal Inspection on 4/26/2022, Staff #1 did not have a National Sex Offender Registry (NSOR) clearance on file. The file for Staff #2 showed that the National Sex Offender Registry (NSOR) clearance on file for Staff #2 was dated 9/24/2021. The file showed that the NSOR clearance was requested on 8/13/2021. The facility did not have a CPSL Provisional Hiring Waiver when Staff #1 and Staff #2 were hired. Staff #2 also did not complete the mandated reporter training until 2/27/2022. See code sheet for dates of hire.

During the Renewal Inspection on 4/26/2022, the surface on the side of the 2nd step to the sliding board was cracked and sharp edges were exposed.

During the Renewal Inspection on 4/26/2022, the Fire Drill and Fire Detection Log did not document that the fire detection system in the facility has been getting tested at least every 30 days.

During the Renewal Inspection on 4/26/2022, The files showed that Staff #1, Staff #2 and Staff #3 had not yet completed professional development in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR). Staff #1, Staff #2 and Staff #3 all have been working at the facility for longer than 90 days. See code sheet for dates of hire.