Lancaster YWCA Child Enrichment Center

It was verified through multiple written and verbal statements that Child #1 was left unsupervised on a bus for a total period of 22 minutes as a result of Staff Person #1 and #2 not completing name/face checks of each primary care group and not completing a thorough visual check of the bus seats after unloading children. The initial directed plan of correction for inspection #00269297 [7.8.25] resulted in approved plan of correction from the provider. However, on 10.9.25 the provider did not satisfy the requirements of that directed and accepted plan that multiple specific staff positions were mandated to attend.

The file of facility person #1 contains a National Sexual Offender Registry dated 3.3.20 which is more than 60 months old. The file for facility person # 4 does not contain a completed National Sexual Offender Registry [NSOR]. Although the LE could hire this person provisionally, the requirement to have the NSOR on file prior to begin working with children under the CPSL has not been met. The file of facility person #5 contains a National Sexual Offender Registry dated 3.3.20 which is more than 60 months old. The file of facility person #6 contains a PA Child Abuse Clearance dated 3.24.20 which is more than 60 months old. The file also does not contain a completed PA State Police Criminal Clearance.

Upon completion of an unannounced monitoring inspection, it was observed that a bottle of hand sanitizer [labeled 'Keep out of Reach of Children'] was left accessible to children in care in the school-aged childcare space.

Upon completion of an unannounced monitoring inspection, it was observed that 2-3 damaged ceiling tiles were in the Pre K #4 childcare space AND damage drywall along the right side of the room was also observed.

Upon completion of an unannounced monitoring inspection, it was observed that there were multiple areas [at least 20+] of peeling paint around the perimeter of the school-aged childcare space.

Staff person #1 has completed the health and safety course titled (Get Started with Center-Based Care: Building Blocks for Quality (10 hours)) but has not completed the required health and safety update course titled Pennsylvania Health and Safety Update 2022 (1 hour) training.

Staff person #2 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 training. Staff person #3 has completed Pediatric first aid and CPR training, however (the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum/ the trainer has not provided documentation that they are PQAS-certified in that training curriculum). Staff person #4 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Required Health and Safety training topics training AND Pediatric First Aid/CPR training. Staff person #7 has completed Pediatric first aid and CPR training, however (the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum/ the trainer has not provided documentation that they are PQAS-certified in that training curriculum).

It was verified through multiple written and verbal statements that Child #1 was left unsupervised on a bus for a total period of 22 minutes as a result of Staff Person #1 and #2 not completing name/face checks of each primary care group and not completing a thorough visual check of the bus seats after unloading children.

It has been confirmed by both verbal statements/internal investigation results provided by Staff Person #2 and Staff Person #3, as well as by direct observation of the incident from facility video footage that Staff Person #1 did in fact leave Child #1 unsupervised in the childcare space while she was sleeping for 2:45.

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: 1. Required Health & Safety training; 2. Pediatric First Aid/CPR.

Upon re-inspection of the physical site to verify implementation of correction plan, it was found that in the Gymnasium play space, a construction area remained unsecured/accessible, which contained chemicals, tools and other items of a hazardous nature.

Upon re-inspection of the physical site to verify implementation of corrective plans, it was found that in the large group room, hand sanitizer and disinfecting wipes remained accessible to children in care.

Upon inspection of the facility to verify the implementation of corrective plans, it was found that a copy of the currently open and active renewal inspection summary was not posted in a conspicuous location used by parents.

Upon re-inspection of the children's files to verify implementation of corrective plans, it was found that the admission agreement document for Child #1 - Child #6 continued to lack a description of the specific services to be provided to the family and the child.

Upon re-inspection of the children's files to verify implementation of corrective plans, it was found that the admission agreement document for Child #1 - Child #6 continued to lack the services which are to be considered as extra.

Upon inspection of the physical site, it was found that in the Gymnasium play space, a construction area was unsecured/accessible, which contained chemicals, tools and other items of a hazardous nature.

Upon inspection of the facility's most up-to-date Emergency Plans, it was found that a specific method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises was not included.

Upon inspection of the facility's most up-to-date Emergency Plans, it was found that a specific method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children was not included.

Upon inspection of the facility's letter to parents regarding emergency procedures, it was found that specific methods of communication in the event of an emergency and at the conclusion of an emergency were not included in the information provided in the letter.

Upon inspection of the physical site, it was found that in the 1-year-old room, there was non-prescription skin cream in one child's cubby; floor cleaner accessible and an unlocked cabinet with cleaning chemicals. In addition, it was found that in the large group room, hand sanitizer and disinfecting wipes were accessible to children in care.

Upon inspection of the physical site, it was found that in the school-aged AND preschool childcare space, the first aid kit was missing tweezers.

Upon inspection of the physical site, it was found that in the Infant childcare space that three ceiling tiles were damaged and one was missing; in the older toddler childcare space that four ceiling tiles were damaged; in the 1-year-old childcare space that one ceiling tile was damaged.

Upon inspection of the physical site, it was found that in the older toddler childcare space that there was chipping paint around the columns; in the 1-year-old childcare space that there was chipped paint on the outside perimeter wall area.

Upon inspection of the physical site, it was found that in the large group room, no visual strips or other visual identification was placed on the glass located within the space.

Upon inspection of the physical site, it was found that in the school-aged childcare space that a table was placed in front of and was blocking a viable exit from the space.

Upon inspection of personnel files, it was found that Facility Person #2 had a health assessment dated 5.26.22 [expired on 5.26.24].

Upon inspection of the physical site, it was observed that in the infant childcare space, bottles were being hand-washed for later use and the staff in that space confirmed that a commercial dishwasher was not used.

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 training. Staff person #2 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 training [documentation on file expired on 11.9.24]. Staff person #3 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 training.

Upon inspection of the children's files, it was found that the admission agreement document for Child #1 - Child #6 did not contain a description of the specific services to be provided to the family and the child.

Upon inspection of the children's files, it was found that the admission agreement document for Child #1 - Child #6 did not specify the services which are to be considered as extra.

During the time of inspection, the facility could not provide documentation of an annual emergency drill being conducted at the facility.

Documentation of the disclosure statement on file for staff member 2 did not include a date in which the disclosure statement was signed by the staff member and witness. Documentation of the disclosure statement on file for staff member 8 was not signed by a witness. Documentation of the child abuse clearance on file for staff member 5 was obtained after the staff members first day caring for children. Updated child abuse clearance and FBI clearance were not on file for staff member 7. The original child abuse clearance on file was dated 9/17/18 and the original FBI clearance was dated 10/6/18. The state police clearance for staff member 7 was updated after the 60-month time frame. The state police clearance expired on 12/7/18 and was updated on 12/8/23. All clearances are to be updated every 60 months.

The emergency plan on file did not include an annual review.

Documentation on file for staff member 1, staff member 2, staff member 4 and staff member 10 did not include emergency plan training.

During the time of inspection, it was observed that outlet covers were missing in a power strip located in the Pre K classroom and Sensory Classroom. This was corrected during the inspection.

During the time of inspection, it was observed that the cleaning solution in the swiffer power mop was within reach of children. The cleaning solution was removed from the mop during the inspection.

During the time of inspection, it was observed that the first aid kit in the school age classroom was missing gloves, soap and scissors. The first aid kit in the toddler classroom was missing scissors and there was only one band aid in the first aid kit in the Pre K classroom. All items were added to the first aid kit in the school age classroom, toddler classroom and pre-k classroom during the inspection.

During the time of inspection, it was observed that ceiling tiles in the infant classroom and toddler classroom had significant water marks on them indicating a leak.

During the time of inspection, it was observed that there was peeling plaster in the older toddler classroom. This was covered with tape during the inspection.

During the time of inspection, it was observed that a toilet was covered with a trash bag in the older toddler classroom and not able to be used and the tank of the toilet in the pre k classroom was covered in a trash bag.

Documentation of the influenza vaccine was not on file for child 3. Documentation on file for child 2 did not include the recommended 15-18 month dose of the DTAP vaccine.

During the time of inspection, it was observed that the medication for child 1 was in the child's bookbag which was within the reach of children.

During the time of inspection, it was observed that medication for child 5 was at the facility but didn't have documentation of a medication log.

Documentation of the letter that the parents receive about the emergency plan did not include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

During the time of inspection, the facility could not provide documentation of an annual emergency drill being conducted at the facility.

A copy of the emergency plan on file was not sent to the county emergency management agency,

Staff member 1 and staff member 4 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR Staff member 2 and staff member 4 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety (CCDBG) Training

Documentation of 12 annual training hours was not on file for staff member 7 and staff member 10.

Documentation of annual fire safety training was not on file for staff member 7, staff member 8 and staff member 10.

Documentation on file for staff member 2, staff member 5 and staff member 6 did not include documentation of two years' experience working with children. Documentation of two years' experience working with children was obtained and placed on file for staff member 2 during the inspection.

Documentation of the agreement on file for child 4 did not include persons designated by a parent to whom the child may be released.

Documentation of the agreement on file for child 1 and child 4 did not include the date of the child's admission.

During the time of inspection, it was observed that the emergency transportation plan was not posted in the sensory room.

Documentation on file for staff member 1, staff member 2, staff member 3, and staff member 9 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. This was corrected on site for staff member 2.

Direct statement from staff person #2, as well as footage from the CC video clearly showed that child #1 was left in the childcare space unsupervised by staff person #1 for a period of time in excess of 9 minutes. Footage indicated that staff person #1 was only 6-8 feet from the sleeping child prior to leaving them unsupervised, and that she also re-entered the childcare space for an unrelated reason and still did not notice the child. Child was observed to be sleeping for part of the time, but then awoke and wandered about the space for a period of time.

Upon investigation of complaint allegations, it was found that the facility had not created a regulatory compliant volunteer file, including CPSL required clearances/registry, for multiple 'chaperones' prior to off-site excursions.

Upon the investigation of complaint allegations, it was found that child #1 was participating in an off-site field trip, during which time they were separated from the primary supervision group for an undetermined amount of time greater than 10 minutes. It was determined that the child remained within the excursion location with a related chaperone, while the primary care group and adult were aboard the transportation bus.

Upon inspection of complaint allegations regarding facility field excursions, it was found that an individual volunteer file had not been created for multiple 'chaperones' prior to these excursions.

The file of facility person #1 does not contain a completed out of state clearances [MD child abuse]. The file for facility person #2 does not contain a valid mandated reporter training certificate [unapproved course 4.21.22].

Upon inspection of facility personnel files, it was found that staff person #3 did not have a record of training on the emergency plan at the time of initial employment.

Upon inspection of the physical childcare spaces, it was found that emergency contact phone numbers were not posted in the sensory and school-aged rooms.

Upon inspection of the physical childcare spaces, it was found that a damaged ceiling tile was in evidence in the toddler 1 room.

Upon inspection of the physical childcare spaces, it was found that there was peeling/flaking paint in the PreK 3 room [pillars & doorframes] AND in the PreK 4 room [windowsills].

Upon inspection of the childcare spaces, it was found that a prescription medication was present for child #1 in the PreK 3 room without any written instructions.

Upon inspection of the physical childcare spaces, it was found that a box of yogurt snacks was placed on the table of the school-aged room at 12:00, which required refrigeration. No staff were present in the room at the time of discovery.

Upon inspection of the fire safety records for the facility, it was found that an purchase attestation statement was not available. Further, upon inspecting the system testing dates, the following dates were provided: 1.2022, 2.2022, 3.31.2022, 4.13.22, 5.16.2022, 6.13.22, 7.11.2022, 8.12.2022, 9.20.2022, 10.18.2022, 11.3.22,12.11.2022 and 1.31.23 - which is evidence that the maximum 30 interval between testing was exceeded on several occasions.

Upon inspection of the facility, it was found that an annual written notification to local traffic safety authorities regarding the program's use of pedestrian and vehicular routes around the child care facility had not been submitted for the past year [20022-2023].

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pre-Service Health and Safety training topics course. Staff person #3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pre-Service Health and Safety training topics course.

Upon inspection of the physical childcare spaces, it was found that a written plan of daily activities was not posted in the sensory and school-aged rooms.

Upon inspection of the physical childcare spaces, it was found that a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency were not posted in the sensory and school-aged rooms.

Upon inspection of the children's files, it was found that the Emergency contact and financial agreement forms for child #2 were last reviewed on 8.8.22 AND the financial agreement form for child #3 was last reviewed on 8.10.22.

Directly observed via video that facility person #1 did physically grab and harshly pull child #2 by the arm during the course of care.

The file of facility person #1 does not contain a completed PA Criminal Clearance.

Upon inspection of facility person #1 file during complaint investigation, it was found that no health assessment was on file.

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

Upon review of the video footage of the specific incident under investigation, staff person #1 can be seen to be roughly moving child #1 in her seat and then making physically inappropriate/rough contact with the child's face area. A full review of the entire day's video footage for that childcare space on 8.23.22 showed staff person #1 use inappropriate physical/rough contact with child #2 - #7.

Upon review of the childcare space video for the entire day of 8.23.22, it was observed that every diaper change completed by both staff persons #1 and #2 [approximately 20+] resulted in the children being immediately returned to the childcare space without their hands being washed with soap and water.

Upon review of the childcare space video for the entire day of 8.23.22, it was observed that on greater than half of the diaper changes completed by both staff persons #1 and #2 [approximately 20+], the diaper changing surface was immediately reused with another child without cleaning the changing surface with a sanitizing solution.

Upon review of the childcare space video for the entire day of 8.23.22, it was observed that every diaper change completed by both staff persons #1 and #2 [approximately 20+] resulted in the child being returned to the childcare space and the next child being changed without either of the staff persons washing their hands with soap and water.

Upon review of the childcare space video for the entire day of 8.23.22, it was observed that child #1, was placed in the quiet cube at 0824 for unknown cause and was not removed from that area until 0842 [17+ minutes] by staff person #1.

After reviewing video footage of the exact incident, written statements by both staff persons #1 and #2 and interview with the facility director, staff person #1 and #2, it was determined that staff person #1 did in fact drag child #1 from one end of the gym to the other.

Upon inspection of the facility emergency plan, it was found that a specific method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises was not developed.

Upon inspection of the facility emergency plan, it was found that a specific method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children was not developed.

Upon inspection of the children's files, it was found that a record of immunizations was not included for #8 [4 years]. Also, no influenza vaccination is included for child #3 [1 year] #4 [3 years], #5 [3 years] and #6 [2 years].

Upon inspection of the facility emergency plan, it was found that specific accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions was not developed.

Upon inspection of the fire drill logs, it was found that drills were conducted on 3.11.21 and then 5.18.21, which exceeds the 60 day limit.

Upon inspection of the facility emergency plan, it was found that specific plans for a lock-down type emergency were not developed.

Upon inspection of the children's files, it was found that an initial health report was not on file for child #8.

Upon inspection of the children's files, it was found that an admission date was missing on the agreements of child #5, #6 and #8.

Upon inspection of the children's files, it was found that the physician's address and phone number were missing from the contact form for child #3 AND the name, address and telephone number of the child's physician or source of medical care was missing from the form for child #8.

Upon inspection of the children's files, it was found that the health insurance coverage and policy number was missing for child #8.

Upon inspection of the children's files, it was found that one address was missing for a designated person for child #5 and #7 AND all addresses were missing for child #8.