Little Lights Christian Academy · Lancaster

It was observed that staff person #1 left the Penguins classroom (young toddlers) out of ratio (11 children to 2 staff) to speak with Cert Rep and Director in the office (corrected during inspection). It was observed that there were 2 staff persons supervising 11 children in the Penguins classroom (young toddlers). The extra child in the room was staff person #2's school-aged child. (corrected during inspection).

Staff person #2 failed to notify the regional office within 24 hours of a child in care at the facility receiving emergency room treatment.

It was observed that staff person #1 did not wash the child's hands after being diapered.

It was observed that staff person #1 did not clean the diaper changing surface after diapering a child.

Staff person #1 did not wash their hands after diapering a child.

Child #1 was in the Penguins (young toddler) classroom with his parent, who is also a staff person. There was no file for child #1 at the facility.

Staff person #2's NSOR certificate on record expired (dated 11/14/19) and was working with children during this visit. Staff person #5's file required some out of state clearances, which were not on record (NJ State Sex Offender Registry and NJ child Abuse & Neglect Registry). Staff person #5's record was corrected during the inspection. Staff person #7's file did not contain a PA State Police clearance, the NJ Sex Offender registry clearance (corrected during inspection) and the NJ Child Abuse clearance. See Code Sheet

Staff person #7's file did not contain a dated Disclosure Statement.

Staff person #2's record did not contain documentation of emergency plan training within one year prior to the current emergency plan training on 2/28/25.

It was observed, in the Owls classroom, that the following toxins were accessible to children, in the Art closet: Windex, Bleach, and Resolve. (corrected during inspection).

It was observed, in the Infant room, that the wooden cabinet directly above the changing table would not remain closed. (corrected during inspection)

It was observed, in the Penguins classroom, that a toddler was sitting in the bucket seat (inserted into table) and the seatbelt was missing. This seat was not being used according to manufacturer's instructions. (corrected during inspection)).

It was observed, in the Owls classroom, that the rest equipment was not labeled for the use of specific children (corrected during inspection).

Staff person #2 did not wash the child's hands after completing a diaper change for that child. (corrected during inspection).

Staff person #7's health assessment on record did not include an examination for communicable diseases and the results of that examination and information on medical problems that might threaten the health of the children or prohibit a staff person from providing adequate care to children.

Staff person #1 used hand sanitizer on her hands (instead of soap and water) after completing a diaper change. Staff person #2 washed her hands with water only (no soap) after completing a diaper change. (both corrected during inspection).

Three children, in the Infant room, did not have current written feeding schedules from the parent at the facility.

Proof of current liability insurance was not on file at the facility.

Staff person #6 did not renew the pediatric first aid and CPR training before the expiration of the most current certification (Jan 2023, Feb 17, 2025).

Staff persons #4, #7, and #8 have no proof of completing the following required pre-service training on file within 90 days of their date of hire: Pediatric first-aid and CPR See Code Sheet

Staff person #2's file does not contain a written evaluation every 12 months (none on file since 2020). Staff person #3's file does not contain a written evaluation every 12 months (Aug 2023 is most current).

Child #1's agreement did not specify the amount of the fee to be charged per day or per week. (corrected during inspection)

Child #2's emergency contact information did not include the enrolling parent's home and work telephone numbers.

It was observed that there are hazards on the large outdoor playground. There are wooden beams embedded in the ground which are a tripping hazard. There is a pipe sticking out of the ground beside the stairs on the big climber.

It was observed that a toilet in the Owls boys' bathroom is not in proper working order (not flushing) and had a strong odor.

The capacity of the Infant room was exceeded when 2 young toddlers were brought into the room (mealtime) without this increase in capacity being designated on the facility's Daily Activities.

Staff persons #1's file did not contain proof of completing the one-hour Health and Safety Training update. Staff person #2 completed the Health and Safety training on 2/5/19, which is outside of the accepted dates for this training (accepted dates are 9/30/16 through 6/30/18).

Staff person #2's file was not available upon request by the Certification Representative.

Staff person #3 witnessed a child being spanked by another staff person (twice) yet did not report the suspected abuse to Childline as is required of all Mandated Reporters. CONTINUED DEFICIENCY: Provider failing to follow the plan of correction regarding this same violation. The required in-person, at least one-hour Mandated Reporter training (for LE, staff, and administration to participate in) was not sent to DHS for pre-approval and completed by 8/30/24, as the provider's plan of correction stated.

Staff person #1 spanked child #1 on two occasions.

Staff person #1's FBI clearance was from the Department of Education rather than the required FBI clearance through DHS

Staff person #3 witnessed a child being spanked by another staff person (twice) yet did not report the suspected abuse to Childline as is required of all Mandated Reporters.

Staff person #2 has acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic.

Staff person #2's record did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #3's record did not contain a child abuse clearance.

It was observed, in Room 4, that the following toxins were accessible to children in a backpack in an unlocked teachers' closet: Edge Fixer (hair product) and nail glue. (corrected during inspection)

It was observed, in Room 3 (Penguins) that the black foams steps used by the children had 3 holes on the surface material, and foam was exposed.

Documentation of the testing of the fire detection system exceeded the at least every 30 days timeframe (12/1/23, 1/5/24), (1/5/24, 2/19/24).

Staff person #1 has acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic.

Staff persons #1 and #2's records did not contain the verification of education and experience required to be considered an Assistant Group Supervisor, yet had functioned as Assistant Group Supervisors (unsupervised with children).

Staff person #1's record does not contain an NSOR certificate or proof that it was applied for prior to working with children. See Code Sheet

The facility's emergency plan does not contain a Continuity Of Operations plan. Staff person #2's record does not contain proof of completion of the required one-hour Health and Safety training update. Staff person #6's completed the required one-hour Health and Safety training update training on 1/22/23, after the deadline of 12/30/22. Staff person #8's has not completed the follwing required pre-service training within 90 days of their date of hire (see code sheet): pediatric first-aid and CPR.

The parent letter explaining the emergency procedures does not contain Lock-Down procedures and accommodations for the evacuation of infants, toddlers, and children with special needs.

It was observed that toxins were accessible to children in the staff bathroom in hall (on shelves): air freshener, Oxiclean, carpet stain remover, Clorox bleach & toilet cleaner, and Mold/Mildew cleaner (corrected during inspection). It was observed in the Giraffes classroom (4 yrs) that toxins were accessible to children on the shelf above the toilet: Clorox toilet cleaner and bleach (corrected during inspection).

It was observed, in the Giraffes classroom (4 yrs) that the first-aid kit did not contain soap. In the Owls classroom (4 & 5 yrs), the first-aid kit did not contain gloves.

It was observed in the Owls classroom (5 yrs) that the teachers' closet contained an accessible industrial paper cutter (corrected during inspection). It was observed in the Monkeys classroom, that the accessible utility closet contained a wooden table and several long pieces of wood leaning against the wall and a box with long pieces of metal and wood leaning against the wall. It was observed that the kitchen is accessible to the children and contained an oven and various sharp utensils. It was observed that the Mechanical Room (inside staff lounge door) was accessible to children and contained 2 ladders leaning against the wall, and several long wires. It was observed, in the Penguins bathroom, that 4 high chairs were stacked which could topple over.

It was observed in the Owls classroom (5 yrs) that there was peeling paint on top of the blue shelf (approx 6 inch area). In the Penguins classroom, it was observed that there was dispersed peeling paint on the blue shelft, under the coat rack.

It was observed in the Penguin classroom that the bathroom light was not functioning properly (flickering) causing the room to be not properly lighted.

It was observed, In the Infant classroom, that the vinyl multi-colored pads contained rips with the foam exposed.

It was observed that mulch with a diameter of less than 1 inch was accessible to children on the Toddler playground (drifts over from playground for 3 yrs and older).

In the Penguins classroom, six of the children's "bucket seats" that are recessed into the table are not being utilized according to manufacturer's instructions: did not contain seatbelts.

It was observed in the Monkeys classroom (2 yrs) that the rest equipment was not labeled for the use of a specified child and used only by the specified child.

It was observed, in the Infant room (Koalas), that there was not 2 feet of space on three sides of the Pack N Plays that were in use (corrected during inspection).

Child #2's most current Influenza immunization on record is dated 9/23/21. Child #4's most current Influenza immunization on record is dated 12/6/19.

It was observed that the dates of administration on a medication log, for a child in the Owls classroom, were left blank.

It was observed in the Penguins classroom that there was no hands-free can near the diaper changing area.

Staff person #4's health assessment on file does not include an examination for communicable diseases and the results of that examination. It also does not include information on medical problems that might threaten the health of the children or prohibit a staff person from providing adequate care to children. This updated health assessment information will be placed in staff person #4's file.

It was observed, in the Infant classroom, that the parents are not signing and dating their written statements giving the formula and feeding schedule and some are not listing the amounts of formula/breast milk to give their children.

The facility's emergency plan does not provide for accommodations for infants, toddlers, and children with disabilities.

No emergency drills were conducted in 2022.

Fire drills were not conducted at least once every 60 days (7/13/22, 9/27/22).

The testing of the facility's fire detection system exceeded the permitted at least every 30 days' timeframe (8/31/22, 10/31/22), (10/31/22, 12/30/22), (12/30/22, 2/22/23).

The facility's emergency plan does not contain Lock-Down emergency procedures.

Child #2's emergency contact information did not include the enrolling parent's home telephone number.

Child #6's emergency contact information did not include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Staff person #2's record does not contain acceptable verification of education (no US equivalency, and Certificate from a higher institution is from another country) and no proof of HS education. Staff person #5's record does not contain verification of education (lacking HS diploma). Staff person #6's record does not contain acceptable verification of education (HS diploma is from another country). Staff person #8's record does not contain proof of HS graduation.

Staff person #7's record does not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Staff person #3's record does not contain proof of obtaining 12 clock hours of child care training between 12/19/21 and 12/19/22.

On 07/05/2022 at 4:00 pm, a red mark was observed on the arm of child #1. The incident was not documented at the time the mark was observed and the original report was not given to the parent on the day of the incident. The incident report was completed on 07/07/2022 and a copy of the incident report was not provided to the parent/guardian until 07/08/2022. The incident report was emailed to them at the request of the parent/guardian in lieu of obtaining the original copy.

On 06/28/2022, observed staff person #1, #2 and #3 working together in the toddler classroom. Staff person #2 did not have the results of the PA State Police or FBI clearance on file to be a provisional hire. Staff person #2 had the results of the Child Abuse Clearances and documentation of a request for the NSOR 06/14/2022 and FBI fingerprinting on 06/18/2022. Staff person #3, was a provisional hire waiting for the results of the NSOR clearance which was requested on 05/05/2022. Staff person #1 had complete clearances on file but did not meet the qualifications of a permanent employee.

Observed mini Pack N Plays in the infant classroom with regular size Pack N Play sheets on the mattresses in lieu of sheets intended for a mini Pack N Play mattress. Observed compact cribs in the infant classroom with regular sized sheets on the mattresses in lieu of sheets intended for a compact crib. The sheets were too big for the mattress and created access material which creates a potential suffocation hazard.

On 06/28/2022, observed staff person #4 and #5 supervising a group of 7 school-age children and 11 preschool children. Staff person #4 identified her group as the 7 school-age children. Staff person #5 identified her group as the 11 preschool children. Staff person #5 was over ratio based on preschool ratios of 1:10.

On 07/28/2022, staff person #4 and #5 were observed working in the Owls classroom supervising a group of 7 school-age children and 11 preschool age children. Staff person #2 identified 7 school-age children in her assigned group. Staff person #5 initially identified the 5 preschool children sitting a the table with her as her assigned group. She did not include the 4 preschool children playing on the carpet, 1 preschool child in the bathroom or 1 preschool child playing at a different table nearby as a part of her group.

Observed diaper creams in the cabinet below the changing table with a broken latch. The diaper creams were accessible to older toddlers in care.

Observed a broken latch on the diaper changing table located in the young toddler classroom.

Observed a toilet in the preschool bathroom with a chair over the toilet to prevent use due to the toilet not flushing properly. Observed the sink in the young toddler classroom was not working Observed the toilets in the boys bathroom in the older preschool classroom were visibly dirty in the corner, on the toilet bowl and on the seats. According to staff at the facility the bathrooms are cleaned weekly.

On 06/28/2022, staff person #1, #2 and #3 were observed to be caring for children in the young toddler classroom (Penguins) unsupervised by an individual who has completed the required training. Staff person #1, #2 and #3 have not completed the following pre-service training required prior to caring for children unsupervised: (1) Prevention and control of infectious diseases (including immunization) and the establishment of a grace period that allows homeless children and children in foster care to receive services under this subchapter while their families (including foster families) are taking necessary action to comply with immunization and other health and safety requirements. (2) Prevention of Sudden Infant Death Syndrome and use of safe sleep practices. (3) Administration of medication, consistent with standards for parental consent. (4) Prevention of and response to emergencies due to food and allergic reactions. (5) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water and vehicular traffic. (6) Prevention of shaken baby syndrome and abusive head trauma. (7)…

Staff Member #1 admitted to Child #1 being supervised by Staff #2 in the facility kitchen to keep a classroom in ratio. Facility kitchens may not be used as classroom space due to the hazards within.

Staff Member #1 admitted to Child #1 being supervised by Staff #2 in the facility kitchen to keep a classroom in ratio. Facility kitchens do not have safe or appropriate activities for children in care.

On 4/8/22, it was observed that CPSL (Child Protective Services Law) was not followed. Staff person 1 did not have clearances or provisional paperwork on file before starting with children. State police clearance was dated 3/8/22, child abuse clearance was dated 3/11/22, FBI clearance was dated 2/11/22. Child Abuse clearance must be on file before starting with children. Either the State Police or the FBI clearance must be on file and provisional paperwork must be in place for the other before starting with children. Staff person 5 had a FBI clearance on file for the Department of Education. All childcare staff must have a FBI clearance for the Department of Public Welfare. Staff person 5 may not work until the correct FBI clearance is on file. CORRECTED Staff person 3 did not have a NSOR (National Sex Offender Registry) certificate on file before starting with children. NSOR certificate was dated 3/25/22. NSOR certificate must be on file before starting with children.

On 4/8/22, it was observed that an outlet cover was missing in the Koala/Infant room. CORRECTED ON SITE.

On 4/8/22 it was observed that there were surfaces in need of repairs: Peeling Paint was observed in the Monkey classroom on the wall by the blue chair (CORRECTED 4/25/22), in the Owl classroom behind the striped chair (CORRECTED 4/25/22), In the penguin room on the side of the white cabinet (CORRECTED 4/25/22).

On 4/8/22, it was observed that some furniture/equipment was in need of repairs: In the monkey room, the blue chair was observed to be worn with exposed stuffing. CORRECTED 4/19/22 In the penguin room a protruding screw was observed on the bookshelf. CORRECTED 4/18/22

On 4/8/22, it was observed that staff person 5 did not update their health assessment in a timely manner. A health assessment was on file that expired on 8/15/21. A new health assessment was not obtained until 8/25/21.

On 5/1/22, it was observed that proof of purchase was not on file for the fire/smoke detection system. Fire System Affirmation is required.

On 4/8/22, it was observed that staff persons 5, 6, and 8 did not complete Health and Safety Training in the first 90 days of hire. Staff person 5 did not have a Health and Safety training on file and was past their first 90 days of employment. CORRECTED 5/27/22 Staff person 6 did not have a Health and Safety training on file and was past their first 90 days of employment. CORRECTED 5/3/22. Staff person 8 had a Health and Safety training on file dated 4/8/22 which was more than 90days after their start date.

On 4/8/22, it was observed that child 7 was enrolled and did not have parent signatures on file for permission for minor first aid or emergency medical care. CORRECTED 4/19/22

On 5/1/22, it was observed that staff persons 5, 6, and 8 had not completed pediatric first aid and CPR in a timely manner. Staff person 5 had been employed for longer than 90 days and had not completed Pediatric first aid and CPR training. CORRECTED 5/27/22 Staff person 6 had been employed for longer than 90 days and had not completed Pediatric first aid and CPR training. CORRECTED 5/3/22 Staff person 8 had been employed for longer than 90 days and had not completed Pediatric first aid and CPR training. CORRECTED 5/27/22