ST JOSEPHS HILL LUTHERAN CHURCH DAY CARE CENTE

Age and Training (3270.31(a))

During a renewal inspection on 9/11/25 it was noted Facility Person 17 is a volunteer and was 15 years old at date of hire. See LIS code sheet for Date of hire and date of birth. Requirement: A volunteer shall be 16 years of age or older and shall be directly supervised at all times by a staff person. Correction: Facility Person 17 is a volunteer and is now 16 years old. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency info/agreement updated 6 mos (3270.181(c))

During a renewal inspection on 9/17/25 it was noted Child 2's emergency contact form and fee agreement were most recent reviewed by the child's parent on 2/11/25, which is more than 6 months ago. Requirement: 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: Director will review emergency contact form and fee agreement with Child 2's parents and have them sign the forms. 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))

During a renewal inspection on 9/11/25 it was noted the following staff had more than 24 months between their health assessments. Staff 2 (2/7/23 & 3/17/25), Staff 3 (3/23/23 & 5/8/25), Staff 4 (3/6/23 & 4/21/25), Staff 8 (7/22/22 & 8/23/24), Staff 10 (2/3/23 and 3/24/25), and Staff 15 (6/8/22 & 8/22/25). Staff 15 was on leave from 8/23/24-6/2/25 and returned to providing care 6/9/25. It was reported Staff 2, 3, 4, 8, and 10 worked in a childcare role between the date when their previous health assessment expired and when the new health assessment was obtained. 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: Staff health assessments were completed on the following dates: Staff 2 (3/17/25), Staff 3 (5/8/25), Staff 4 (4/21/25), Staff 8 (8/23/24), Staff 10 (3/24/25), and Staff 15 (8/22/25). Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Toddler/preschool: updated health report every 12 months (3270.131(b)(2))

During a renewal inspection on 9/17/25 it was noted that the most recent health report for Child 8, an older toddler, was dated 4/23/24, which is more than 12 months ago. Requirement: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. Correction: Director will inform the parents of Child 8 to provide a valid health assessment. Parent will provide a health assessment by the correction date. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written emergency plan posted/Manufacturer's instructions used (3270.124(e)/3270.175(c))

During a renewal inspection on 9/11/25-9/17/25 Cert rep observed Rooms 1 and 6 did not have the facility emergency medical transportation plan posted. Cert rep observed the Ford Transit 350 did not have the emergency medical transportation plan present. It was reported staff would not have been taking the emergency medical transportation plan with them when using the Ford Transit 350 to transport children to and from school. Cert rep observed the Ford Transit 350 did not have the manufacture instructions present for the child booster seats that were used in this vehicle. Requirement: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children. Manufacturers' instructions for use of safety restraints shall be kept in the vehicle at all times. Correction: The emergency medical transportation plan was posted in Room 1 and 6, and was added to the Ford Transit 350. The manufacturing instructions for the booster seats were added to the the Ford Transit 350. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Designated release persons/Admission date (3270.123(a)(5)/3270.123(a)(6))

During a renewal inspection on 9/17/25 Child 6 did not have the release persons on their fee agreement. Children 3, 4, 5, 7, 8, and 10's fee agreements did not list their date of admission. Requirement: An agreement shall specify the persons designated by a parent to whom the child may be released. An agreement shall specify the date of the child's admission. Correction: Date of admission was added to Children 3, 4, 5, 7, 8, and 10's fee agreements. Release Person information was added to Child 6's fee agreement. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency Numbers Posted/Posted in group space (3270.74/3270.111(b))

During a renewal inspection on 9/11/25 Cert rep observed the telephone number of the nearest hospital, police department, fire department, ambulance and poison control center was not posted by the telephone in Room 1. Cert rep observed the daily schedule was not posted in Rooms 1 and 6. Requirement: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility. The written plan of daily activities shall be posted in the group space. Correction: The daily activities were posted in room 1 and 6. The emergency telephone numbers were posted by the phone in Room 1. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

During a renewal inspection on 9/11/25 Cert rep noted the following staff had more than 12 months between their staff evaluations: Staff 1(9/1/23 & 9/1/25), Staff 5 (11/28/23 & 8/29/25), Staff 7 (9/3/23 & 9/3/25), Staff 11 (11/20/23 & 8/7/25), Staff 12 (12/7/23 & 8/28/25), and Staff 15 (5/13/24 & 9/5/25). Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Staff have valid evaluations on file dated respectively: Staff 1(9/1/25), Staff 5 (8/29/25), Staff 7 (9/3/25), Staff 11 (8/7/25), Staff 12 (8/28/25), and Staff 15 (9/5/25). Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

During a renewal inspection on 9/11/25 Staff 9 had emergency plan trainings dated 6/10/24 and 7/18/25, which is more than 12 months between trainings. Requirement: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility. Correction: Staff 9 had emergency plan training 7/18/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

During a renewal inspection on 9/11/25 the following staff did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Staff 6 (Pediatric first aid and CPR), and Staff 14 (PA Required Health and Safety for Centers-Group Child Care Part 1 and Part 2). Staff 6 completed Pediatric first aid and CPR on 1/8/25, and Staff 14 completed PA Required Health and Safety for Centers-Group Child Care Part 1 on 4/22/25 and Part 2 on 6/1/25. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: Staff 6 completed Pediatric first aid and CPR on 1/8/25, and Staff 14 completed PA Required Health and Safety for Centers-Group Child Care Part 1 on 4/22/25 and Part 2 on 6/1/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During a renewal inspection on 9/11/25 Facility Person 16 had FBI clearance dated 11/17/24 and NSOR clearance dated 2/11/25, which are after the volunteer's first day with children. Volunteer 16 had FBI request date 11/15/24(after first day with children), and NSOR request dated 10/16/24(before first day with children), however Facility Person 16 was working as a volunteer and was not able to be provisionally hired. (See LIS code sheet for first day with children). 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. Correction: Facility Person 16 has FBI clearance dated 11/17/24 and NSOR clearance dated 2/11/25. 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))

During an unannounced inspection on 4/30/25 Cert rep noted 3 incidents of more than 30 days between fire detection testing: 10/9/24-12/9/24, 12/9/24-2/7/24, and 3/5/25-4/30/25. 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: The Director or designated person will test the manual fire detection system within every 30 days. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

During an unannounced inspection on 4/30/25 Cert rep observed Plastic bags and gloves on the changing table in the infant room. Children in this room may still be putting things in their mouths. These items would be accessible while the children are being changed. Requirement: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths. Correction: The plastic bags and gloves on the changing table in the infant room were immediately made inaccessible to the children. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

During an unannounced inspection on 4/30/25 Cert rep observed Desitin and butt paste in an unlocked accessible cabinet under the changing table in the infant room and Start Right water conditioner and Sludge destroyer in an unlocked cabinet under the sink in the big room. These items are labeled "keep out of reach of children." Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Items marked "keep out of reach of children" infant products were locked in the changing table cabinet. Cleaning items that were marked "keep out of reach of children" in the big room were immediately made inaccessible to the children. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

During unannounced inspection on 4/30/25 Staff person 1 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): PA Required Health and Safety training. This is evidence by PA Required Health and Safety training dated 10/2/24 Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: The staff person 1 completed the required professional development PA HEalth and Safety training on day 91 of their date of hire. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Staff person #1 has a volunteer state police clearance dated 8/23/23, and a volunteer child abuse clearance dated 8/29/23. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1 may not work in a child care position at the facility. 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. Correction: Staff person #1 was suspended as an employee until which time she attained an employee state police and child abuse clearance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Pertinent Laws & Regulations/General Health and Safety (3270.14/3270.21)

The facility does not have a policy to address continuity of operations. Requirement: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Correction: The center has created a continuity plan of operations that will be placed in policy, implemented into emergency training and presented to parents on September 11th every year as part of the center's emergency procedures. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).