Shady Lane School

The file for Staff #8 contained a PA Child Abuse clearance dated 9/14/25 which was obtained after starting in a child care position (See LIS Code Sheet). The file for Staff #12 contained an FBI Clearance dated 5/28/25 and NSOR Certificate dated 5/30/25 which were obtained after starting in a child care position (See LIS Code Sheet). The file for Staff #12 lacked the required out of state clearances. The file for Staff #16 lacked the required out of state clearances. The file for Staff #15 lacked an FBI clearance.

The file for Staff #13 lacked a disclosure statement.

The files for Staff #5, #9, #10, #11, and #12 lacked documentation of emergency plan training at initial time of hire. The file for Staff #7 contained emergency plan training dated 7/31/24, more than 12 months ago.

At approximately 3:00pm, CR observed 2 infants sleeping in cribs in the Rainbow Room that lacked at least 2 feet of free space on three sides.

The health assessment on file for Staff #9, dated 8/25/25, was obtained after starting work in a child care position. There is no health assessment on file for Staff #11. The health assessment on file for Staff #14, dated 12/12/24, was obtained after starting work in a child care position.

Documentation of the fire alarm system test shows more than 30 days between testing. (5/7/25 and 6/9/25; 8/14/25 and 9/23/25)

Staff person #2 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): PA Required Health and Safety for Centers-Group Child Care Part 1 and Part 2 dated 4/21/25. Staff person #3 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): PA Required Health and Safety for Centers-Group Child Care Part 1, dated 6/8/25, and Part 2, dated 9/17/25. Staff person #4 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric first aid and CPR training dated 10/12/24. Staff person #9 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Health and Safety training 3270.31(f)(1-9). Staff #12 has completed Pediatric first aid and CPR training, however the training was completed through a trainer that has not provided documentation that they are PQAS-certified in that training curriculum.

The file for Staff Person #1 contained a mandated reporter training dated 5/28/25 which was obtained more than 60 months from the previous mandated reporter training dated 2/25/20.

The files for Staff #9 and #10, identified as GS, lacked documentation of staff qualifications for the position in which they were performing. The file for Staff #16, serving as an aide, lacked documentation of qualifications for the position in which they were performing.

The file for Staff #5 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person. The files for Staff #6, #8, #9, and #10 lacked two written nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Based staff interviews, it was verified that Staff Person #1 and #2 withheld a popsicle from Child #1 on 6/2/25 because the child had refused to take a nap.

4/16/26 between 9:30-10:50AM staff #1 was responsible for the supervision of 11 PS children on 3 occasions. Sixteen children were present. Staff #2 exited the room with 5 children two separate times while Staff #1 remained in the room with the other 11 children. Later, staff #1 exited the room to go to the playground with 11 PS children. Staff #2 remained in the room with 5 children.

At approximately 11:05AM Staff #1 and Staff #2 were observed with 12 children (2 PS and 10 OT) in room 105. When asked to identify the children they were responsible for supervising, staff #1 and staff #2 named the same two children during multiple attempts to identify their assigned groups. This left two children unidentified as assigned to a care group. In the gym, staff #3 and staff #4 were observed with 10 YTs. When asked, staff #4 was unable to identify which children she was assigned to supervise. Staff #4 named 2 children already identified as part of staff #3's assigned care group.

At approximately 10:55AM child #1 and child #2, both infants, were observed sleeping in inclined seats in the Rainbow Room.

Based on the facility's fire drill log, a drill has not been conducted in over 60 days. The last documented drill occurred 1/28/25.

Staff person #5 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Pediatric CPR and Pediatric First Aid.

Staff persons #6, #7, and #8 have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 4/24/20 for staff #6, 1/27/20 for staff #7, and 2/21/20 for staff #8.

The file for Staff Person #4 lacked a current FBI clearance; the FBI clearance in the file for Staff Person #4 was dated 8/22/19. The file for Staff Person #5 contained a Volunteer PA Criminal Clearance. The file for Staff Person #10 lacked a current FBI clearance; the FBI clearance in the file for Staff Person #10 was dated 5/24/19. The file for Staff Person #11 contained an NSOR dated 11/6/19 which was obtained more than 60 months ago. The file for Staff Person #11 contained an FBI clearance dated 12/2/24, more than 60 months from the previous clearance dated 10/17/19. The file for Staff Person #12 lacked an NSOR clearance as well as a DHS FBI clearance. The file for Staff Person #12 contained a Criminal Justice FBI clearance dated 8/28/24. The file for Staff Person #13 contained a PA Child Abuse clearance dated 11/23/24 which was obtained after starting in a child care position (See LIS Code Sheet). The file for Staff Person #25 lacked a Texas Criminal History Check and the Texas Sex Offender Registry Check.

The facility's emergency plan lacked a method for facility persons to inform parents that the emergency has ended and instructions as to how parents can safely be reunited with their children as per Announcement C-22-04.

The parent letter lacked information explaining the emergency procedures for lockdown situation and accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

There was a hot water tank accessible to the children in an unlocked cabinet under the sink in the bathroom connected to the Blue room.

There is peeling paint in the Red room under the mirror. There is peeling paint in the Orange room around the far left window and around the stars along the window wall.

The toilet in the bathroom off the Violet room lacked a handwashing sign. The sink in the bathroom off the Red room lacked a handwashing sign.

The bathroom off the Blue room lacked a lidded waste receptacle.

The play couch in the Orange room has a ripped vinyl covering on the corner, exposing foam padding to children still placing objects in their mouths. The changing pad in the Silver room has a hole in the final covering.

The cribs in the Rainbow Room lacked 2 feet of space around them while in use. An infant was sleeping in a crib in the corner next to the rocking chair and there was a bouncy seat on the other side of the crib impeding access. Another child was observed sleeping in a crib next to two other empty cribs on either side less than 2 feet apart.

The health report on file for Child #5, a toddler (See LIS Code Sheet), was dated 7/29/24 more than 6 months after the previous health report dated 7/31/23. The health report for Child #6, a toddler (See LIS Code Sheet) was dated 11/4/24 more than 6 months after the previous health report dated 4/20/24.

The file for Child #7, enrolled more than 60 days, lacked verification of vaccinations in accordance with the ACIP.

The file for Staff Person #15 (See LIS Code Sheet) contained a health assessment dated 8/14/23, and TB screening results dated 8/21/23 which were more than 12 months old when hired. The file for Staff Person #18 (See LIS Code Sheet) contained a health assessment dated 1/8/24 which was more than 24 months from the previous health assessment dated 12/29/21. The file for Staff Person #12 (See LIS Code Sheet) lacked a health assessment. The file for Staff Person #24 (See LIS Code Sheet) lacked a health assessment.

The health assessment on file for Staff Person #4 (See LIS Code Sheet) lacks assessment results for communicable diseases.

The facility lacked a current annual emergency drill. The most recent emergency drill was recorded on 11/16/23, more than 12 months ago.

Documentation of the fire alarm system test shows more than 30 days between testing. (11/1/24 and 12/6/24; 8/5/24 and 9/9/24; 3/7/24 and 4/8/24)

The facility's policy for Shaken Baby Syndrome/Abusive Head Trauma lacked prevention and identification of child maltreatment as per Announcement C-22-03.

The file for Staff Person #1 lacked the one hour Health and Safety Update as per Announcement C-22-06.

Staff Person #7 completed pediatric first aid and CPR training on 10/12/24, more than 24 months from the previous training on 8/11/22. Staff Person #14 completed pediatric first aid and CPR on 5/24/24 more than 24 months from the previous training on 3/8/22.

The file for Staff Person #11 contained a mandated reported training dated 8/26/19 which was obtained more than 60 months ago.

The file for Staff Person #1 lacked a copy of their High School Diploma and years of experience working with children. The file for Staff Person #12 lacked documentation of education and years of experience working with children. The file for Staff Person #16 lacked documentation of experience working with children. The file for Staff Person # 21 lacked documentation of education and years of experience working with children. The file for Staff Person #22 lacked documentation of education and years of experience working with children. The file for Staff Person #23 lacked documentation of education and years of experience working with children. The file for Staff Person #24 lacked documentation of education and years of experience working with children.

The file for Staff Person #7 contained a staff evaluation completed in October 2024 more than 12 months after the previous staff evaluation dated June 2022; The file for Staff Person #19 contained a staff evaluation completed in October 2024 more than 12 months after the previous staff evaluation dated May 2022.

The agreement form for Child # 1 lacked the signature of the operator.

The files for child #4, #5, #6, #9 & #10 contained child growth and development forms dated more than 6 months ago. The file for Child #4 contained a child growth and development form dated 9/24/23. The file for Child #5 contained a child growth and development form dated 10/13/23. The file for Child #6 contained a child growth and development form dated 10/25/23. The file for Child #9 contained a child growth and development form dated for the Fall of 2023. The file for Child #10 contained a child growth and development form dated October 2023.

The file for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10 contained the original fee agreement form signed by the parent.

The emergency contact form for Child #7 lacked the name of the physician or source of medical care.

The emergency contact form for Child #1, Child #4, Child #5, Child #6, Child #8 and Child #10 lacked the enrolling parent's work address and work phone number; The emergency contact form for Child #3 lacked the enrolling parent's home address, work address, and work phone number.

The emergency contact form for Child #1 lacked the release person's address and phone number; The emergency contact forms for Child #3, Child #8, Child #9, and Child #10 lacked the release person's address.

The Pink room lacked a copy of the emergency transportation plan displayed conspicuously in the child care space.

The financial agreement for Child #4 was last updated on 7/25/23, more than 6 months ago. The emergency contact form for Child #10 was updated on 9/6/24 more than 6 months after the previous review dated 9/18/23. The financial agreement for Child #10 was updated on 11/12/24 more than 6 months after the previous review dated 12/5/22.

The files for Staff Person #16, Staff Person #20, and Staff Person #21 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person. The files for Staff Person #1, Staff Person #5, Staff Person #12, Staff Person #13, Staff Person #15, Staff Person #22, Staff Person #24, and Staff Person #25 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

The files for Staff Person #3, Staff Person #8, and Staff Person #9 completed professional development in pediatric first aid and pediatric CPR on 5/24/2024, more than 90 days following their date of hire (See LIS Code Sheet). The file for Staff Person #4 lacked a pediatric first aid and pediatric CPR training provided by a certified PQAS instructor more than 90 days following their date of hire (See LIS Code Sheet). The pediatric first aid and pediatric CPR on file for Staff Person #4 completed on 4/14/24 was not provided by a certified PQAS instructor. The files for Staff Person #5 completed professional development in pediatric first aid and pediatric CPR on 12/10/2024, more than 90 days following their date of hire (See LIS Code Sheet). The files for Staff Person #6 completed professional development in pediatric first aid and pediatric CPR on 12/10/2024, more than 90 days following their date of hire (See LIS Code Sheet).

The file for Staff Person #2 contained 3 of the 12 required annual training hours for the most recent review period, June 2023 and June 2024.

Staff #1 and staff #2 were supervising a group of 9 younger toddlers in the facility's outdoor play space. As staff #1 and staff #2 were transitioning the children from the building to the area designated for younger children in the outdoor play space, child #1 stopped midway between the two points while the staff and children continued to move ahead. Child #1 was left alone and unsupervised until staff #3 entered the outdoor play space and discovered the child had been left behind.

Staff #1 and staff #2 were supervising a group of 9 younger toddlers in the facility's outdoor play space. As staff #1 and staff #2 were transitioning the children from the building to the area designated for younger children in the outdoor play space, child #1 stopped midway between the two points while the staff and children continued to move ahead. Child #1 was left alone and unsupervised until staff #3 entered the outdoor play space and discovered the child had been left behind.

Garbage bags were being stored in an unlocked cabinet under the diaper changing table in room 101, accessible and posing a suffocation hazard to children in care.

The record for Staff Person #7 included a current State Police Clearance dated more than 60 months following the date of their previous clearance. The record for Staff Person #10 and #11 included a current State Police Clearance dated more than 45 days following their first day working at the facility. The record for Staff Person #11 included a current NSOR Verification Certificate dated more than 45 days following their first day working at the facility. The disclosure statement in the record for Staff Person #10, #12 and #20 were not dated. The record for Staff Person #17 did not include a disclosure statement. The record for Staff Person #21, who has resided out of state within the past five years, did not include the required out of state clearances.

Reports of accidents, injuries and illnesses involving children in care at the facility were not retained at the facility in an accident file.

Staff Person #2, #3, #5, #7, #8 and #9 did not receive training regarding the emergency plan on an annual basis during the period of time between the dates of their current and previous trainings. Staff Person #6, #10 and #15 received training regarding the emergency plan more than 90 days following their date of hire. (See LIS Code Sheet)

The operator did not provide to the parent of each enrolled child a letter explaining the emergency procedures.

There was sunscreen being stored in an unlocked cabinet under the diaper changing table in room 101.

There was no door or other barrier being used to prevent children from entering the kitchen area from the hallway, which made the kitchen stove and warming equipment, sources of heat exceeding 110°, accessible to children in care.

A handwashing sign was not posted at the sink in room 105.

The bathroom in room 104 was equipped with a waste receptacle that was not lidded.

The record for child #6 lacked a current health report.

There was no means for children to dry their hands after handwashing at the sink in room G4.

The TB results for Staff Person #4 were read after the staff person's start date. The file for Staff Person #5 did not include an updated health assessment conducted within the past 24 months. The date of the initial health assessment for Staff Person #6, #11 and #15 was after their start date. (See LIS Code Sheets). The current health assessment for Staff Person #7, #8, #9 and #13 was dated more than 24 months following the date of their previous health assessment. The initial health assessment for Staff Person #12 was conducted more than one year prior to the staff person's start date and is not valid.

A written statement giving the formula and feeding schedule was not obtained from the parents of child #8 and #9, who are both infants.

Written notification of safe routes were not posted in the child care facility.

A fire drill was not conducted at least once every 60 days during the period from 10/20/2023 to 1/3/2024.

Testing of fire detection system every 30 days was not documented.

The record for child #2, #4 and #5 lacked an initial health report more than 60 days following their first day of attendance. The record for child #7 contained an initial health report dated more than 60 days following their first day of attendance.

The operator did not notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

The operator's policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment did not address the prevention and identification of child maltreatment, as per Announcement C-22-03. Staff Person #5, #7, #8, #9, #13, #14 and #19 completed the Pennsylvania Health and Safety Update 2022 following the prescribed timeframe of December 30, 2022, as required by OCDEL per Announcement C-22-06.

The current Pediatric First Aid/CPR certification for Staff Person #18 was completed following the expiration of their previous certification.

Staff Person #2, #5, #7, #8 and #9 did not participate in fire safety training, at least annually, during the period of time between their current and previous training.

Staff Person #1 did not complete the following required pre-service training within 90 days of their date of hire: CCDBG Health and Safety training. (see LIS code sheet)

Staff Person #6, #15, #16 and #19 completed the CCDBG Health and Safety training more than 90 days following their date of hire. (See LIS Code Sheet)

The director did not complete a written evaluation for Staff Person #8 within the past year.

The record for Staff Person #1 lacked verification of the required education and child care experience for them to be qualified to work as an assistant group supervisor.

The written plan of daily activities was not posted in room 111.

The agreement for child #1 did not specify the amount of the fee to be charged per day or per week.

The agreement for child #2 did not specify the persons designated by a parent to whom the child may be released.

The emergency contact information for child #4 did not include the name, address and telephone number of the child's physician or source of medical care.

The emergency contact information for child #4 did not include the written consent signed by a parent for emergency medical care.

The emergency contact information for child #4 did not include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

An emergency contact form was not present in room G1 for child #10 who was receiving care in the space.

A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not displayed in room G1 and room 201.

The record for child #3 and #7 did not contain signed parental consent for administration of minor first-aid procedures by facility staff.

The record for staff #1 and #10 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

The Pediatric First Aid/CPR Certification in the record for Staff Person #16 was completed more than 90 days following their date of hire. (See LIS Code Sheet)

The file for Facility Person #1 lacked a request for an NSOR Certificate prior to starting at the facility. The NSOR certificate on file was dated 14 days after starting at the facility.

The file for Facility Person, a Staff Person, #3 lacked a Child Abuse Clearance that had been completed for employment purposes. The Child Abuse Clearance on file was a Volunteer Clearance. The files for Facility Person's #6 and #9 lacked a signed disclosure statement prior to starting at the Facility. The disclosure statements were completed 14 days after starting for both Facility Persons. The mandated reporter training on file for Facility Person #8 was not completed within 90 days of starting at the facility. The training was completed 97 days after starting at the Facility.

The emergency plan on file at the facility lacked continuity of operations in the aftermath of a disaster as required by Federal Regulation.

The first aid kit in Classroom #102 was observed in an unlocked backpack on a low chair that could be accessible to children receiving care in the space.

A lidded can was missing from a sink in Classroom 203.

A cracked bin with a potential pinch point was observed in Classrooms 201 and 203. In Classroom #104 a torn cushion was observed on a couch intended for children receiving care in the space.

The file for Child #5, an infant, lacked an updated health report that had been completed within the last 6 months. The last assessment on file was dated 1.4.22.

The current health report on file for Child #2 lacked information to include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. The assessment also lacked a statement that they had received age-appropriate screenings recommended by the AAP since the time of the previous health report.

The immunization record on file for Child #3 lacked verification that they had received their 6-month DTAP, HIB and Pneumococcal immunizations. The immunization record on file for Child #4 lacked verification that the child has received an annual influenza vaccination. Written exemptions were not on file for children.

An Auvi Q medication was observed in an unlocked backpack on a low chair in Classroom #102. The unlocked backpack could be accessible to children receiving care in the space.

The current health assessment on file for Facility Person #5 lacked the results of an examination for communicable diseases.

The health assessment on file for Facility Person #10 lacked information related to the physician's assessment of their suitability to provide child care.

The emergency plan on file lacked information related to accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

The file for Child #1, an older toddler, lacked an initial health assessment and the child has exceeded 60 days in care at this time (refer to LIS code sheet).

The health and safety training on file for Facility Person #8 was not completed within 90 days of starting at the facility. The health and safety training was completed 98 days after starting.

The written staff evaluations on file for Facility Person #2 were dated 8.23.21 and 10.18.22. The written staff evaluations for Facility Person #4 were dated 8.10.21 and 9.12.22. The written staff evaluations for Facility Person #5 were dated 8.21.21 and 10.4.22. Written evaluations are to be completed at least once every 12 months.

The updates to the emergency contact forms and financial agreements on file for Children #2, #4 and #6 exceeded 6 months between updates. The emergency contact forms on file for Child #2 were dated 8.11.21 and 5.13.22 and the agreement was dated 8.26.21. The emergency contact forms on file for Child #4 were dated 3.31.22 and 12.4.22 and the agreement on file is dated 4.5.22. The emergency contact forms on file for Child #6 were dated 2.9.22 and 11.13.22 and the agreement forms were dated 2.27.22 and 12.7.22.

The file for Facility Person #7 lacked two written, nonfamily references attesting to their suitability to serve as a facility person.

The disclosure statement in the file for staff person #9 and #13 were not able to be verified timely as neither document was dated. Based on review of the file for staff person #11 and on conversation with the individual, they had resided in Nevada in the previous 5 years and their file did not include any of Nevada's clearances. The FBI clearance and NSOR Certificate in the file for staff person #11 was dated after they began working with children. Based on review of the file for staff person #14 and on conversation with the individual, they had resided in DC in the previous 5 years and their file did not include any of DC's clearances. The FBI clearance and NSOR Certificate in the file for staff person #14 was dated after they began working with children. The state police clearance in the file for staff person #14 was missing a disposition when the individual began working with children and they continued to work without the disposition for approximately 2 months. The child abuse, FBI and NSOR certificate in the file for individual #15 were dated after the individual began working as a facility person. The facility did not have a provisional hire waiver at the time of the…

At approximately 10:45 am, staff persons #3, #4 and #5 were in the Gold room with 4 infants. Staff person #4 was sitting in a rocking chair holding child #2 in their arms. When asked to identify the children for whom they were responsible, staff person #4 identified child #1, a 2 month old, who was asleep in a crib on the back wall of the room. With the lights dimmed in the room, based on the position of the crib, the direction the child was laying and where staff person #4 was sitting, the staff person could not see the child's face or assess the child at that time.

At approximately 10:30 am, in the orange room, staff person #1 and #2 were present with 8 older toddlers. Staff person #1, who was sitting on the carpeted floor with a group of children, identified 2 children that were in the classroom bathroom, which they could not see, hear, direct or assess from where they were sitting.

The emergency plan training in the file for staff person #11 was dated after their initial employment. Facility person #15 had emergency plan training, but the training was not documented.

In the large indoor gym, observed a large loft. On the first landing of the loft, observed carpet which was starting to come loose and was fraying. This causes a tripping hazard to the children in care.

The most recent list of immunizations in the file for child #3, a 2 year-old, was missing 1 of 4 Pneumococcal vaccines. The last flu shot in the file for child #5, a 2 year-old, and child #8, a 4 year-year old, was in 2020. The most recent list of immunizations in the file for child #6, a 5 year-old was missing the following vaccinations: 2 of 3 Hep B, 2 of 4 DTAP, 3 of 4 HIB, 3 of 4 pneumococcal, 2 of 3 polio and 1 of 2 Hep A. None of the files included a written statement of exemption by a parent.

The health assessment in the file for staff person #5, #8, #9, #10 and #11 was dated after they began working with children. The health assessment in the file for staff person #12 was more dated more than 12 months before the individual began working with children. The last 2 health assessments in the file for #19 were dated more than 24 months apart.

The TB screening in the file for staff person #5, #8, #10 and #11was dated after they began working with children. There was no evidence of a TB screening in the file for staff person #2.

There was not written notification of safe pick-up and drop-off routes posted at a conspicuous location at the facility.

The facility did not have proof of purchase of their fire detection system, which is interconnected.

The facility has general liability insurance, but a copy of the current policy was not on file at the facility.

The last 2 Mandated Reporter trainings in the file for staff person #20 were dated more than 60 months apart. The file for facility person #21, employed more than 90 days, did not include Mandated Reporter training.

The initial evaluation in the file for staff person #17 was dated more than 12 months after the individual began working with children. There was no evaluation in the file for staff person #23, employed more than 12 months. The last two evaluations in the file for the following staff were dated more than 12 months apart: 1, 3, 18, 20, 22, 26, 27, 28 and 30.

Based on review of the file for staff person #2 and #7, both holding the title of group supervisor, they did not have the qualifications to be a group supervisor because they did not have an associates degree. Based on review of the file for staff person #8, holding the title of group supervisor, they did not have qualifications to be a group supervisor as their bachelor's degree was in an unrelated field and did not include 30 credits in a related field.

The agreement forms in the file for child #2, #4, #5, #6 and #7 included two different colors of ink and the director confirmed that those forms were the originals.

The emergency contact information in the file for child #7 did not include dad's work address.

The last update in writing by a parent on the agreement form in the file for child #6 was dated more than 6 months ago.

The file for staff person #8 and facility person #21did not include any letters of reference. The file for staff person #14 and #15 included only 1 letter of reference.

There was no health and safety training in the file for staff person #24, employed more than 90 days.