YMCA/Northwestern Elementary

The facility fire alarm test log identifies that alarm tests exceeded 30 days between tests from 1/16/2025 to 2/24/2025 and from 2/24/2025 to 3/27/2025 and a fire system inspection report within the previous 12 month period was not available. The facility is located in a school building and classes were in session, so the provider was not able to demonstrate that the alarm system is operational.

The file for staff person #1 contains current mandated reporter training that was competed greater than 60 months after the previous mandated reporter training as evidenced by trainings dated 1/30/2020 and 2/8/2025. The training is now current.

The gym play space is lacking a written plan of daily activities.

The preschool classroom sink is lacking a lidded waste receptacle.

The file for staff person #1 contains a current health assessment that was obtained greater than 24 months after the previous health assessment. The file is now current.

On the day of inspection the provider was unable to demonstrate that the fire alarm is operational due to being located in a school with a different legal entity and was unable to provide the current fire system inspection report.

Staff persons #1 and #5 were observed to be caring for children unsupervised. Staff persons #1 and #5 have not completed the following pre-service training required prior to caring for children unsupervised: Pediatric First-Aid & CPR Training.

The file for staff person #1, whom was hired as the director on (See LIS Code Sheet), lacked a Child Abuse Clearance and an FBI Clearance that was completed 60 months from the previous clearance. The Child Abuse Clearances in the file were dated 7/6/18 and 7/28/23. The FBI Clearances in the file were dated 6/28/18 and 8/1/23. The file for staff person #3, whom was hired as an AGS on (See LIS Code Sheet), lacked a dated disclosure statement. The file for staff person #4, whom was hired as an AGS on (See LIS Code Sheet), lacked a Child Abuse Clearance.

The facility lacked an emergency plan that addressed continuity of operations.

It was observed that the operator did not review the emergency plan within the past year. The last review was done on 7/29/21.

The file for staff person #1 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file was dated 1/10/22 and 8/1/23. The file for staff person #2 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file was dated 6/6/22 and 8/1/23. The files for staff persons #3 and #4 lacked emergency plan training that was completed 90 days from the hire date (See LIS Code Sheet). The emergency plan training in the file was dated 8/1/23 and 8/2/23. The file for staff person #5 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file was dated 8/18/21 and 8/1/23. The file for staff person #6 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file was dated 9/30/21 and 8/1/23. The file for staff person #7 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file was dated…

It was observed that the provider did not provide to the parent of each enrolled child a letter explaining the lock-down procedures and the special accommodations for children with special needs and chronic medical conditions.

In Room 600 a broken plastic bin was observed to have rough edges and sharp corners.

It was observed that an emergency drill was not conducted in the past year.

The facility lacked an emergency plan that included accommodations for shelter of children during an emergency including lock-down.

The file for staff person #6 lacked firesafety training that was completed one year from the current firesafety training. The firesafety training in the file was dated 1/13/22 and 5/3/23. The file for staff person #7 lacked firesafety training that was completed within the last year. The firesafety training in the file was dated 7/28/22.

Staff persons #1, #3, #5, and #7 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 Training.

The file for staff person #2 lacked a staff evaluation written by the director within the past year. The staff evaluation in the file was dated 7/15/22. The file for staff person #5 lacked a staff evaluation written by the director 12 months from the previous staff evaluation. The staff evaluations in the file were dated 8/10/21 and 1/20/23. The file for staff person #7 lacked a staff evaluation written by the director within the past year. The staff evaluation in the file was dated 8/10/21.

The files for children #1, #2, and #3 lacked agreement forms.

The file for child #3 lacked an agreement that specified the date of the child's admission.

The file for staff person #2, whom was hired as an assistant group supervisor on (SEE LIS CODE SHEET), lacked an NSOR verification certificate in the file prior to working with the children. The NSOR verification certificate in the file is dated 6/8/22. The file for staff person #3, whom was hired as an assistant group supervisor on (SEE LIS CODE SHEET), lacked an FBI clearance in the file prior to working with the children. The FBI clearance in the file is dated 10/13/21.

It was observed in the restroom above 2 sinks handwashing signs were not posted. It was observed in the boys restroom that a handwashing sign was not posted above the toilet in one stall. It was observed in the girls restroom that 3 handwashing signs were not posted above the toilets in three stalls.

The file for staff person #1 lacked a health assessment that was completed 24 months from the previous health assessment. The health assessments in the file were dated 2/12/20 and 3/17/22.

The fire drill log was observed. Smoke detector checks were conducted more than 30 days apart. The smoke detector checks were 37 days between 9/15/21 and 10/22/21; 31 days between 1/21/22 and 2/21/22; 33 days between 3/18/22 and 4/20/22; 37 days between 5/11/22 and 6/17/22; 42 days between 7/5/22 and 8/16/22.

The file for staff person #1 lacked mandated reporter training that was completed 60 months from the previous mandated reporter training. The mandated reporter trainings in the file are dated 2/23/17 and 6/30/22.

2nd citation; originally cited 8/20/2021: In the cafeteria child care space there is a stage with steps accessible to the children and a barrier is not in place on the edge of the stage.

2nd citation; originally cited 8/20/2021: The white classroom refrigerator is lacking a thermometer.

2nd citation; originally cited 8/20/2021: The files for child #2 and #3, all school aged, lack immunization reports and have been in attendance for greater than 60 days.

2nd citation; originally cited 8/20/21: The facility emergency plan does not include accommodations for infants, toddlers, children with disabilities and children with chronic medical conditions.

2nd citation; originally cited 8/20/2021: The provider does not have proof of purchase of the hard-wired interconnected fire detection system. The annual fire inspection report by a fire safety professional shows uncorrected deficiencies. The facility does not have documentation of 30 day fire system tests.

2nd citation; originally cited 8/20/2021:The files for children #2 and #3, all school aged, lack health assessments and have been in attendance for greater than 90 days.

2nd citation; originally cited 8/20/2021: The file for staff person #1 does not include documentation of professional development in the health and safety topics within 90 days of employment.