Willow Cove Early Learning Center

The file for Staff person #1 (See IS Code Sheet), who has resided out of state within the previous five years, was observed to lack a New Jersey Sex Offender Registry Check Child as required by the Child Protective Service Law (CPSL). The staff file for Staff person #2 contained a current State Police clearance dated 7/18/25, a current Child Abuse clearance dated 7/21/25 and a current DHS FBI clearance dated 7/22/25 all of which were not renewed within 60 months of the previously dated 6/3/20 State Police clearance, 6/2/20 Child Abuse clearance and 6/11/20 DHS FBI clearance expiring. The file for staff person #5 was observed to contain a current National Sex Offender Registry (NSOR) check dated 8/27/25 which was not obtained prior to first day working with children (See IS CODE SHEET) required for provisional hiring under the CPSL.

The refrigerator located in the Littles Room was observed to lack a thermometer.

The child file for Child #1, who is a preschool age child, was observed to contain an updated health report dated 4/1/25 which was conducted more than 12 months from the previously dated 3/26/24 health report on file.

The staff file for Staff person #4 contained a current health assessment dated 3/3/25 which was not conducted prior to providing initial service in a childcare setting. The staff file for Staff person #8, contained a current health assessment dated 9/22/25 which was conducted more than 24 months from the previously dated 11/15/22 health assessment on file.

The staff file for Staff person #6 contained a current health assessment dated 9/5/24 that lacked examination for communicable diseases and the results of that examination.

The staff file for Staff person #6 contained a current health assessment dated 9/5/24 that the physician's or CRNP's assessment of the person's suitability to provide childcare.

Upon observing the breakfast menu, it was observed that only 2 out of 3 food groups were being offered during the week: either cereal and milk, French toast and milk, Waffles and milk, and pancakes and milk.

The current annual fire system inspection report was not on file at time of inspection and was not done annually. The previous inspection report on file was dated 9/9/24. Staff person #9 reported the fire company was at the facility to test the alarms the morning of 10/8/25 however a written report of that test was not on file at time of inspection.

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 #3 and Staff person #7 had 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 since completed the training on 9/16/25 and Staff person #7 on 9/27/25.

The staff file for Staff person #2 contained current mandated reporter training dated 7/19/25 which was not renewed within 60 months from the previously existing mandated reporter certificate dated 7/18/20.

Per staff statements Child #1, an infant age child, was fed puffs on 11/19/24 without parental consent.

At approximately 1:40pm, in the Older Toddler Room during nap time, the room was observed to lack adequate lighting thus making is difficult for staff to see the children's faces in order to properly supervise the children as they napped.

***At approximately 1:35pm, during naptime in the PS 4 Room, one staff and 15 preschool age children were observed. During the onset of supervision/ratio check, Staff person #1 identified and named only 7 children thus leaving the other 8 children unaccounted for. When asked who was responsible for the 8 unnamed children Staff person #1 said Staff person #4, who was out of the room on their break, was responsible for those children. At approximately 1:40pm, during naptime in the Older Toddler (Nursery Room), one staff and 12 older toddlers were observed. During the onset of supervision/ratio check, Staff person #10 identified and named only 6 children thus leaving the other 6 children unaccounted for. When asked who was responsible for the 6 unnamed children Staff person #10 said Staff person #6, who was out of the room on their break, was responsible for those children.

**At approximately 1:35pm, during naptime in the PS 4 Room, one staff and 15 preschool age children were observed. During the onset of supervision/ratio check, Staff person #1 identified and named only 7 children thus leaving the other 8 children unaccounted for. When asked who was responsible for the 8 unnamed children Staff person #1 said Staff person #4, who was out of the room on their break, was responsible for those children. At approximately 1:40pm, during naptime in the Older Toddler (Nursery Room), one staff and 12 older toddlers were observed. During the onset of supervision/ratio check, Staff person #10 identified and named only 6 children thus leaving the other 6 children unaccounted for. When asked who was responsible for the 6 unnamed children Staff person #10 said Staff person #6, who was out of the room on their break, was responsible for those children.

*At approximately 1:35pm, during naptime in the PS 4 Room, one staff and 15 preschool age children were observed. During the onset of supervision/ratio check, Staff person #1 identified and named only 7 children thus leaving the other 8 children unaccounted for. When asked who was responsible for the 8 unnamed children Staff person #1 said Staff person #4, who was out of the room on their break, was responsible for those children. At approximately 1:40pm, during naptime in the Older Toddler (Nursery Room), one staff and 12 older toddlers were observed. During the onset of supervision/ratio check, Staff person #10 identified and named only 6 children thus leaving the other 6 children unaccounted for. When asked who was responsible for the 6 unnamed children Staff person #10 said Staff person #6, who was out of the room on their break, was responsible for those children.

The staff file for Staff person #8 lacked documentation of having participated in annual emergency plan training for 2024; the last documented training was dated 8/21/23.

At approximately 10:28am, in the Infant Room, an infant was observed to be asleep in a crib that was up against another crib resulting in there not being at least 2 feet of space on three sides of the crib while it was in use.

The staff file for Staff person #3, contained a current health assessment dated 5/7/24 which was conducted more than 24 months from the previously dated 3/11/22 health assessment on file. The staff file for Staff person #4, contained a current health assessment dated 7/8/24 which was conducted more than 24 months from the previously dated 6/28/22 health assessment on file. The staff file for Staff person #6 contained a current health assessment dated 3/20/24 and tuberculosis screening test and results dated 3/11/24 which were not conducted prior to providing initial service in a childcare setting.

An annual emergency drill was observed to be conducted on 8/2/24 which was more than 12 months after the previously documented emergency drill dated 5/8/23.

Observed the annual fire system inspection report was completed more than 12 months after the previous inspection report. The previous inspection report was dated 5/31/23 and the most recent inspection report is dated 9/9/24.

The staff file for Staff person #2 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 8/1/24 and 7/25/23. The staff file for Staff person #4 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 8/1/24 and 7/26/23.

Staff person #5 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training; Staff person #5 has since completed the training on 1/12/24.

The staff file for Staff person #5 contained current mandated reporter training dated 3/18/24 which was not renewed within 60 months from the previously existing mandated reporter certificate dated 2/5/19.

The staff file for Staff persons #2, #3, #4, and #7 contained a current staff evaluation that was not dated therefore it cannot be determined if the staff evaluations were completed at least once every 12 months from the previously dated 9/27/23 staff evaluation on file.

The staff file for Staff person #4 who is functioning as an Assistant Group Supervisor, lacked one year of experience working with children. The staff file for Staff person #9 who is functioning as an Assistant Group Supervisor, lacked two years of experience working with children; only 2, 078 hours were documented.

The child file for Child #1 contained a current emergency contact form that was not reviewed and signed by the parent every 6 months; the two most recent reviews of the emergency contact form were signed on 5/24/23 and 12/5/23.

In the PK 4 Room, 3 staff and 21 PreK children were observed. When asked to name the children in their respective supervision groups, the following occurred: Staff person #1 stated that 7 children were in their supervision group, but only named 4 and disclosed they did not know the names of the other three children in their group. Staff person #2 took approximately 3 minutes to match names to children in their group and after naming the 9th child in their supervision group, children in the room reminded Staff person #2 that the child they named was not in attendance. Staff person #3 required assistance from Staff person #2 to say the names of the two children in their supervision group. Therefore, it was determined that the staff did not know the names of all of the children in their respective supervision groups

As a result of a complaint investigation conducted on 8/5/24, it was determined that the facility failed to inform parents of enrolled children during specific and separate outbreaks of COVID and Hand, Foot Mouth disease.

In the Nursery School Room (Older Toddler Room) an electrical outlet located on the wall above the small children's bookshelf and accessible to children under 5 years of age was observed to be missing an outlet cover.

Based on staff interviews a child who was excluded from care for having a communicable disease was permitted to return to care without a doctor's note indicating that they are no longer considered a threat to the health of others.

Based on staff interviews multiple staff who were excluded from working at the facility for having a communicable disease were permitted to return to work without a doctor's note indicating that they are no longer considered a threat to the health of others.

The staff file for Staff person #1, who is functioning as an assistant group supervisor, contained a foreign diploma that lacked additional documentation to show that the diploma had been evaluated to determine its validity and whether or not it meets qualifications for the position.

The staff file for Staff person #1 who is functioning as an Assistant Group Supervisor, lacked proper documentation of verification of two years' experience working with children; Staff person #1 disclosed that they filled out the employee verification form themself and did have the previous employer complete to verify employment.

The staff file for Staff person #1, who is functioning as an assistant group supervisor, contained a foreign diploma that lacked additional documentation to show that the diploma had been evaluated to determine its validity and whether or not it meets qualifications for the position.

Staff person # 1 did not complete the following required pre-service training within 90 days of their date of hire. SEE IS CODE SHEET. The current revised 10-hour health and safety training is now on file and dated 1/2/24.

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 2/5/19.

The file for Staff person #2 was observed to lack a valid DHS FBI Clearance. The file for Staff person #3 was observed to contain a Child Abuse Clearance on file dated 5/23/23 which was not obtained prior to hire (See IS CODE Sheet). The file for Staff person #7 was observed to contain a National Sex Offender Registry (NSOR) check on file dated 10/26/22 and there was no documentation of having applied for the NSOR check prior to date of hire (See IS CODE SHEET) required for provisional hiring under the CPSL. The file for Staff person #8 was observed to lack a valid DHS FBI Clearance; A Department of Education (DOE) FBI clearance was on file which is not an acceptable FBI clearance per the Child Protective Service Law (CPSL).

The sink in the Infant Room, which is occasionally used by toddlers whenever they receive care in that space, was observed to lack a platform or steps for the toddlers to use while washing their hands.

The sink in the Young Toddler Room was observed to lack a handwashing sign.

The child file for Child #1, who was a young toddler at the time, was observed to contain an updated health report dated 2/6/23 which was conducted more than 6 months from the previously dated 1/10/22 health report on file. The child file for Child #2, who is a young toddler, was observed to contain health reports that were conducted more than 6 months apart; those health report dates are dated 9/30/22 and 12/13/21. The child file for Child #3, who is a young toddler, was observed to contain health reports that were conducted more than 6 months apart; those health report dates are dated 10/3/22 and 10/4/21.

The file for staff person #4 was observed to lack a health assessment on file prior to hire (See IS CODE SHEET); The health assessment on file for staff person #4 is dated 9/20/23. The file for staff person #6 was observed to lack a health assessment on file prior to hire (See IS CODE SHEET); The health assessment on file for staff person #6 is dated 4/12/23. The file for staff person #8 was observed to lack a health assessment on file prior to hire (See IS CODE SHEET); The health assessment on file for staff person #8 is dated 10/3/23.

The staff file for Staff person #4 contained a current tuberculosis screening and results dated 9/29/23 which was not conducted prior to providing initial service in a childcare setting. The staff file for Staff person #6 contained a current tuberculosis screening and results dated 4/12/23 which was not conducted prior to providing initial service in a childcare setting.

Staff person #10 through Staff person #15 had not completed the one-hour Pennsylvania Health and Safety Update 2022 training by 12/30/22 as required per announcement C-22-06. All staff have now completed the required training.

In the PS 3 Room a stapler was observed stored in a 3-tier rolling cart accessible to the preschool age children in care.

Staff person #1, Staff person #2 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. Staff person #1 and Staff person #2 have since completed the training. Staff person #6 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Updated 10hr. Health and Safety Training; the 6hr and 1hr Health and Safety Trainings were on file which are not acceptable for new staff hired after 10/4/22. Staff person #7 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. Staff person #7 has since completed the training. Staff person #9 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety training and Pediatric First Aid/CPR. Staff person #9 has since completed the trainings.

Staff person #1 had not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 10/2/18. Staff person #1 completed the required mandated reporter training on 10/18/23. Staff person #3 had not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). Staff person #3 has since completed the training on 5/17/23.

The file for staff person #1 lacked a disclosure statement on file at time of hire a disclosure dated 10/12/22 is on file. Staff person #2 lacked a valid DHS FBI clearance at time of hire; a DOE FBI clearance dated 5/13/20 was on file which is not an acceptable FBI clearance per the Child Protective Service Law (CPSL). The file for staff person #3 was observed not to contain a National Sex Offender Registry (NSOR) certificate within 45 days of hire (See IS CODE SHEET). Staff person #3 also lacked a valid DHS FBI clearance at time of hire; a DOE FBI clearance was on file which is not an acceptable FBI clearance per the Child Protective Service Law (CPSL). The file for staff person #4 was observed to lack a valid DHS FBI clearance; a DOE FBI clearance was on file. The file for staff person #5 was observed not to contain a NSOR certificate within 45 days of hire (See IS CODE SHEET). Staff person #5's NSOR certificate is dated 9/23/22. The file for staff person #6 lacked a Child Abuse clearance prior to hire (See IS CODE SHEET); Staff person #6 has a Child Abuse clearance on file dated 3/29/22. Staff person #6 was also observed not to contain a NSOR certificate within 45 days of hire…

In PS 4 Room a container of push pins were observed inside the top left desk drawer which was unlocked and accessible to children in care.

The sink located within the Young Toddler room was observed to lack a platform or steps for the young toddlers to use while washing their hands.

Staff person #6 self reported that after a young toddler's diaper is changed that child's hands are cleaned with a baby wipe and not washed at the sink with soap and water.

The child file for Child #3, who is a preschool age child (See IS CODE SHEET), was observed to contain an updated health report dated 10/3/22 which was conducted more than 12 months from the previously dated 4/8/21 health report on file. The child file for Child #4, who is a preschool age child (See IS CODE SHEET), was observed to contain an updated health report dated 10/6/22 which was conducted more than 12 months from the previously dated 9/22/21 health report on file. The child file for Child #6, who is a preschool age child (See IS CODE SHEET), was observed to contain an updated health report dated 10/6/22 which was conducted more than 12 months from the previously dated 8/9/21 health report on file.

In Preschool 4 room a Tylenol was observed to lack the name of the child for whom the medication is intended to be used by.

The file for staff person #2 was observed to not contain documentation of a health assessment being completed within 12 months prior to date of hire (See IS CODE SHEET). The health assessment on file for staff person # 2 is dated 6/30/22. The file for Staff person #12 lacked a health assessment on file prior to date of hire {See IS CODE SHEET).

The file for staff person #2 was observed to not contain documentation of a tuberculosis screening and the results prior to date of hire (See IS CODE SHEET); the tuberculosis screening on file for staff person # 2 is dated 6/30/22. The file for Staff person #12 lacked tuberculosis screening and the results on file prior to date of hire (See IS CODE SHEET). The file for staff person #10 was observed to not contain documentation of a tuberculosis screening and the results prior to date of hire (See IS CODE SHEET); the tuberculosis screening on file for staff person #10 is dated 9/21/22.

The staff file for Staff Person #8 contained a current health assessment dated 8/25/22 that lacked the physician's or CRNP's assessment of the person's suitability to provide child care.

The current fire inspection was not conducted annually as evidence by the last two fire inspections were dated 4/7/22 and 2/22/21.

The facility emergency plan lacked information regarding volunteer emergency preparedness and continuity of operations included in their emergency plan. The facility also lacked a handwritten policy and procedure identifying the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment.

Staff person #1, #3, #5, #7, #12, #13, and #14 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First-Aid/CPR.

The staff file for Staff person #3 and Staff person #10 and Staff person #11, who are functioning as a Group Supervisor, contained a bachelor of science diploma that did not list the degree awarded thus making is difficult to determine if the degree is in a related human service field.

The staff file for Staff person #2, who is functioning as an Assistant Group Supervisor, lacked one year of experience working with children. The staff file for Staff person #4, Staff person #7, Staff person #9, and Staff person #12 who are all functioning as Assistant Group Supervisors, lacked two years of experience working with children.

The child file for Child #7 and Child #8 contained a financial agreement form that lacked the child's admission date.

The child file for Child #2 contained an emergency contact information form that lacked the name of the child's physician.

The child file for Child #1 contained an emergency contact information form that lacked the address for one of the designated release persons.

The child file for Child #2 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the last two reviews for the emergency contact form were dated 10/10/21 and 6/20/22 and were 1/11/22 and 9/9/22 for the financial agreement. The child file for Child #3 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the last two reviews for the emergency contact form were dated 10/5/21 and 9/15/22 and were 1/3/22 and 8/14/22 for the financial agreement. The child file for Child #4 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the last two reviews for the emergency contact form were dated 1/24/22 and 9/19/22 and were 1/3/22 and 9/19/22 for the financial agreement. The child file for Child #5 contained a financial agreement that was not reviewed and updated by the parent at least once in a 6-month period; the last two reviews for the financial agreement were dated 1/3/22 and…

The file for Staff person #12 lacked a health assessment and tuberculin skin test on file prior to date of hire {See IS CODE SHEET).

The staff file for Staff person #10 and Staff person #12 lacked one nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Upon review of the facility's fire drill log it has been more than 60 days since a fire drill was conducted as evidence by the last documented fire drill was conducted on 6/7/22.

Upon review of the facility's fire alarm testing log it has been more than 30 days since the fire alarms were tested as evidence by the last documented test was conducted on 7/7/22.

The emergency exit door in the infant room was obstructed with a pack n play and a rocking chair.

Child file #1 lacked documentation of annual influenza vaccination administered in accordance with the schedule recommended by the ACIP.

The facility's emergency plan lacked a plan that provides accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Staff file #1 contained documentation of mandated reporter training completed on 6/24/15 and 7/18/20 which exceeded the 60 months as required by CPSL.

Staff files #2, #3 and #4 lacked documentation of completion of Pediatric First Aid and Pediatric CPR within 90 days of hire.,