CHESTERBROOK ACADEMY

Fire safety - 1 yr. (3270.31(e)(4)(ii))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/8/26, the staff files were reviewed. The file for Staff Person #6 did not contain fire safety training that was completed in the past twelve months. The most recent fire safety training on file for Staff Person #6 was dated 2/17/25. Requirement: Staff persons shall participate, at least annually, in fire safety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent. Correction: Staff person #6 will complete their 2026 fire safety training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL/CPSL information (3270.32(a)/3270.192(4))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/8/26, the staff files were reviewed. The file for Staff Person #1 did not include a PA State Police Clearance for employment. (There was a volunteer PA State Police Clearance on file for Staff Person #1 dated 11/3/25). The file for Staff Person #2 did not include a PA Child Abuse Clearance for employment. (There was a volunteer PA Child Abuse Clearance on file for Staff Person #2 dated 1/29/25). The FBI Clearance on file for Staff Person #2 had been stapled in the corner with the attached pages torn off. The rap sheet that had been attached to the FBI Clearance of Staff Person #2 was missing from the file. The clearances for Staff Person #3 included the staff's address in NJ. Staff Person #3 stated that they moved to NJ in 6/2025. The PA Clearances for Staff Person #3 were updated in 8/2025, but the out-of-state clearance was not requested at that time. The FBI Clearance for Staff Person #3 was not updated within 60 months. This is evidenced by the clearances on file being dated 8/13/20 and 9/7/25. The file for Staff Person #4 did not include an FBI Clearance or an NSOR that had been completed within the past 60 months. This was evidenced by the clearances on file being dated: FBI 11/30/20 and NSOR: 10/19/20. The clearances for Staff Person #5 were not updated within 60 months. This is evidenced by the clearances on file being dated: State Police: 11/17/20 and 2/6/26, Child Abuse Clearance: 11/17/20 and 2/12/26, and FBI Clearance 12/1/20 and 2/24/26. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #1 may not work in a child care position at the facility until a State Police Clearance for employment is on file. Staff Person #2 may not work in a child care position at the facility until a PA Child Abuse Clearance for employment is on file and a complete FBI Clearance, including the rap sheet, is on file. Staff Person #3 may not work in a child care position at the facility until a NJ Child Abuse Clearance is on file. Staff Person #4 may not work in a child care position at the facility until a current FBI Clearance and NSOR are on file. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #1 may not work in a child care position at the facility until a State Police Clearance for employment is on file. Staff Person #2 may not work in a child care position at the facility until a PA Child Abuse Clearance for employment is on file and a complete FBI Clearance, including the rap sheet, is on file. Staff Person #3 may not work in a child care position at the facility until a NJ Child Abuse Clearance is on file. Staff Person #4 may not work in a child care position at the facility until a current FBI Clearance and NSOR are on file. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a hiring checklist. The checklist should include an outline of what needs to be in a staff file and by when. The hiring checklist must be submitted to Northeast Regional Office for approval. Once approved, the child care center will use the hiring checklist whenever a new staff is hired. The operator shall provide a correction date for when the tracking document will be completed. Correction: 1. 6/8/26 The center will comply with the CPSL and with Chapter 3490. Staff Person #1 will not work in a child care position

Contaminated trash in closed plastic-lined receptacle (3270.67(d))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, a trash can that was not plastic lined was observed in the bathroom in the Beginner A Room. Requirement: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. Correction: The extra garbage can near the sink that was used for paper towels will be removed completely and will no longer be used. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, a broken storage tote was observed on the playground. Requirement: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts. Correction: The broken tote was removed and thrown away. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Refrigerator (3270.107)

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, a broken thermometer was observed in the refrigerator in the Toddlers Room. Requirement: A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator. Correction: The broken thermometer will be replaced. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Signed (3270.123(a))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, the child files were reviewed. The fee agreement for Child #3 was not signed by the operator. Requirement: An agreement shall be signed by the operator and the parent. Correction: All current child files will be inspected to ensure all fee agreements are signed by parents and the operator. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physician name, address, phone/Insurance coverage information (3270.124(b)(2)/3270.124(b)(6))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, the child files were reviewed. The emergency contact information for Child #1 did not include the phone number of the child's physician or the health insurance coverage and policy number. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable. Correction: The emergency contact form will be updated to include the missing information. All current child files will be inspected to ensure all emergency contact forms are completed in entirety. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Updated every 6 months/Emergency info/agreement updated 6 mos (3270.124(f)/3270.181(c))

A renewal inspection was conducted on 6/2/26 and 6/8/26. On 6/2/26, the child files were reviewed. The emergency contact form and fee agreement for Child #2 had not been updated since 10/1/25, more than six months prior to the inspection. The fee agreement for Child #3 had not been updated since 10/1/25, more than six months prior to the inspection. Requirement: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information. Correction: The emergency contact forms and fee agreements of the children will be reviewed and updated by the parents. All current child files will be inspected to ensure all required forms are updated no less than every 6 months or when there is a change in information Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces/Clean and good repair (3270.76/3270.102(a))

An inspection was conducted on 8/19/25 as a result of an incident report made by the facility. On 8/12/25, Child #1 was standing behind the door of the Toddler Room, unseen by a parent entering the room. When the parent opened the door, the child's finger was pinched between the door and door jam, fracturing the child's finger. Requirement: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts. Correction: A warning sign has been posted on the Toddler room door instructing to visually confirm no children are behind the door before entering. Pinch guards will be installed. Inspection: Incident Investigation. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e))

A renewal inspection was conducted 6/17/25. At that time, the staff files were reviewed. The file for Staff Person #1 only included verification of 5.5 hours of child care training completed during the training year 3/18/24-3/18/25. An additional 6.5 child care training hours is required. Requirement: A staff person shall obtain an annual minimum of 12 clock hours of child care training. Correction: Staff Person #1 will complete a 6.5 hours of child care training hours. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

A renewal inspection was conducted 6/17/25 and 6/27/25. During the file review, Staff Person #5 only had one written nonfamily letter of reference on file. Requirement: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Correction: Staff Person #5 will submit a second written nonfamily letter of reference to be placed in their file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter (3270.151(a))

A renewal inspection was conducted 6/17/25 and 6/27/25. During the file review, Staff Person #3 did not have a health assessment on file that was completed within 12 months of their date of hire. The health assessments on file for Staff Person #3 was dated 4/2/25 and 11/30/22. Requirement: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. Correction: In the future, staff will submit a health assessment when they begin employment that was completed within 12 months prior to their hire date and will be updated every 24 months thereafter. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Medication log (3270.133(7))

A renewal inspection was conducted 6/17/25. At that time, staff stated that Hyland's Teething Gel was administered to Child #1 at least two times the previous week, but a medication log was not established for administration of the medication. Requirement: An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered. Correction: Staff will complete a medication log when the Hyland's Teething Gel is administered. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Review policies and procedures (3270.121(a))

A renewal inspection was conducted 6/17/25 and 6/27/25. At that time, the family handbook did not include the facility's policy on supervision. Requirement: The operator shall review with the parent, at the time of application, the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements. Correction: The facility's policy on supervision will be added to the family handbook. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

HS/GED + 2 yrs (3270.36(b)(5))

A renewal inspection was conducted 6/17/25 and 6/27/25. During the file review, Staff Person #5, an assistant group supervisor, did not have documentation of two years' experience working with children on file. Staff Person #5 had documentation of 233 hours working with children and a high school diploma on file. Requirement: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. Correction: Staff Person #5 will submit verification of two years' experience working with children to qualify as an assistant group supervisor. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Bachelor's (3270.35(b)(1))

A renewal inspection was conducted 6/17/25 and 6/27/25. During the file review, Staff Person #3, a group supervisor, did not have documentation of completion of high school or college education on file. Staff Person #3 had 3 years experience working with children on file. Requirement: A group supervisor shall have a bachelor's degree from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field. Correction: Staff Person #3 will submit verification of high school education and will be an assistant group supervisor until they have completed their bachelor's degree. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

A renewal inspection was conducted 6/17/25 and 6/27/25. During the file review, it was found that Staff Person #4 did not update their mandated reporter training within 60 months. This is evidenced by the documented mandated reporter training on file being dated 1/24/20 and 3/16/25. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: A spreadsheet has been created to track when staff are due to update clearances and mandated reporter training. The spreadsheet will notify the director one month prior to the expiration so that the staff person will have adequate time to update the required clearance or mandated reporter training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Devices must be compliant/Director or designated staff person ensure compliance (3270.95(a)/3270.95(b))

An unannounced inspection was conducted on 4/29/25. At that time, the thirty day testing log of the fire detection system was reviewed. The fire detection system had not been tested every thirty days. This was evidenced by the dates of the testing on the log: 12/3/24, 1/3/25, 2/3/25, 3/25/25. Requirement: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met. Correction: Director will conduct fire detection testing no less than every 30 days. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

An investigation was conducted on 4/29/25. During the investigation, it was found that a lapse of supervision occurred on 4/22/25 when Child #1 was found at the beginning of the hallway to the facility by Staff Person #1. Child #1 had left the Beginner B Classroom at the end of the hallway unnoticed by Staff Person #2, Staff Person #3, and Staff Person #4. It was unknown whose supervision group Child #1 belonged to. At the time of the investigation, staff #2, #3, &#4 were no longer employed at the facility. Requirement: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. TIERED LIS: 1. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. This portion of the plan shall have an immediate correction date. 2. The legal entity must update the facility supervision policy in order to maintain proper supervision when a new child is enrolled at the facility. This policy will ensure that all children are properly assigned to a staff person and supervised at all times. The policy should include the procedure for preparing for newly enrolled children, including who is responsible for creating the supervision card and delivering the supervision card and emergency contact form to the child's classroom. The policy should include how staff should determine whose supervision group the new child will be assigned to. The legal entity must receive approval of the policy from the Regional Office. Once approved by the Regional Office, the legal entity must review policy with all staff and have staff sign off that the understand and will follow the supervision policy. The operator shall provide a correction date for when the policy will be reviewed and signed off by all staff. Correction: 1. 4/22/25: Children will be supervised at all times. 2. 6/9/25: Upon enrollment, the Director will inform both the Assistant Principal and Office Administrator the full name and enrollment schedule of the new child. The Principal or Office Administrator will create the initial supervision card and deliver both the supervision card and emergency contact form to the child's classroom and inform the classroom teachers at least one day prior to the child's enrollment date. On the first day of care, the most tenured teacher within the classroom will update the supervision card with a picture of the child for permanent use within the classroom. Staff will evenly split current students into their respective care groups. Going forward, staff will alternate new students into each care group as children are newly enrolled. This procedure will be added to our Supervision Policy and submitted for review to the Regional Office. Once approved, the policy will be reviewed by all staff who will sign off their understanding and consent to follow the policy. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e)(4)(i))

An unannounced inspection was conducted on 4/29/25. At that time, the preservice training for all staff present was reviewed. Staff person #7 had not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training on file expiring 2/2025 and the current Pediatric first aid and CPR training on file dated 4/7/25. Requirement: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Correction: All staff will complete Pediatric first aid and CPR training prior to the expiration of current training. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

An unannounced inspection was conducted on 4/29/25. At that time, the preservice training for all staff present was reviewed. Staff person #5 had not completed mandated reporter training prior to the expiration of their previously completed mandated reporter training. This is evidenced by the previously documented mandated reporter training on file being dated 1/24/20 and the current mandated reporter training being dated 3/16/25. Staff person #6 had not completed mandated reporter training prior to the expiration of their previously completed mandated reporter training. This is evidenced by the previously documented mandated reporter training on file being dated 3/23/20 and the current mandated reporter training being dated 4/21/25. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: All staff will complete Mandated Reporter training prior to the expiration of current training. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Every 60 days (3270.94(a)(1))

An unannounced inspection was conducted on 4/29/25. At that time, the fire drill log was reviewed. The fire drills had not been conducted for 62 days, which was evidenced by the dates of the fire drills on the log: 12/3/24 - 2/3/25. Requirement: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. Correction: Director will conduct fire drills no less than every 60 days. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file (3270.182(7))

A complaint inspection was conducted on 12/10/24. At that time, it was found that an incident report was written on 11/19/24 for Child #1. The incident report was written in response to the parent questioning staff as to how Child #1 was injured on 11/18/24. Requirement: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file. Correction: An updated accident reporting protocal will begin on 12/30/24. Step 1: Accident report is completed as soon as incident has occured and aid is administered if necessary Step 2: Admin is notified of accident report. Step 3: Two copies of accident report are made. Step 4: One copy is provided to parent/guardian Step 5: One copy is placed within child's file Step 6: One copy is placed within the facility master binder Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

A complaint inspection was conducted on 12/10/24. At that time, Staff Person #1 admitted that they do not know how Child #1 was injured on 11/18/24. Child #1 was in the primary care group of Staff Person #1 on 11/18/24. Requirement: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must arrange for Staff Person #1 to complete training regarding Supervision of Children. The legal entity must receive DHS approval of the training content prior to scheduling the training. Correction: Staff person #1 will complete the following trainings after DHS approval: #363797 Infant-Toddler Care: Quality Supervision Self-Learning Module - Better Kid Care Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

A renewal inspection was conducted 11/5/24. At that time, disinfectant spray was observed in an unlocked floor level cupboard where it was accessible to the children in the Beginner B Classroom. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Cleaning materials and anything marked "keep out of the reach of children" will be stored out of the reach of children or within a locked storage area. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).