KELLY AND NINAS DAYCARE

2025

1. Medium-High risk9/12/2025

   Fire safety - 1 yr./Exp, educ., training at facility (3270.31(e)(4)(ii)/3270.192(2)(iii))

   The files for staff person #1 and #2 had fire safety trainings that exceeded a year between trainings. 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: Staff member #1 and staff member #2 have both corrected the Fire and Safety issue by completing the training. #1 completed the training on 2/25/25 and #2 completed the training on 2/28/25 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 2/28/2025
2. Medium-High risk9/12/2025

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

   The file for staff person #3 had a disclosure statement that lacked the signature of a witness. The file for staff person #1 had child abuse clearances that exceeded 60 months between clearances. 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: Staff member #3 resigned the disclosure statement along with the witness signature on 9/15/25. Staff member #1 applied for a new child abuse clearance and received it on 9/5/2025. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/15/2025
3. Medium-High risk9/12/2025

   Protective Outlet Covers 5 yrs. or less (3270.65)

   In the lobby, there was an electrical outlet to the left of the stairs under the bulletin board that lacked 2 outlet covers and was accessible to children 5 years of age and younger. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: The old outlet safety plugs were removed and new outlet plugs were installed on 9/12/2025 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/12/2025
4. Medium-High risk9/12/2025

   Locked or inaccessible (3270.66(a))

   In the toddler room, there was a Febreze Air Freshener that was plugged into the electrical outlet next to the door and contained air freshener liquid that was accessible to children. In an unlocked drawer in a desk in the front office area, there were multiple adult medications including Ibuprofen and Acetaminophen that were labeled "Keep out of reach of children" and were accessible to 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: The Febreze Air Freshener was removed on 9/12/2025 and outlet safety plugs were put in the outlets. All medicine was removed from the desk drawer on 9/12/2025 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/12/2025
5. Medium-High risk9/12/2025

   Building Surfaces (3270.76)

   On the outdoor play space in the back left corner, there were a couple areas along the fence that had sharp nails and edges that were accessible to children. In the young preschool room, there was a rug on the floor that was not secured to the floor and was a tripping hazard. 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. Correction: Maintenance was contacted on 9/15/2025 regarding the issue of debris left behind from the removal of the shed in the back playground area. Their workers removed all fragments of sharp nails, pointed wood, and hard plastic off of the fence and ground area. The rug in the young Preschool classroom has been removed to prevent any injuries from tripping or slipping and falling due to movement of the rug. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/17/2025
6. Medium risk9/12/2025

   No peeling paint or plaster (3270.77(a))

   On the outdoor play space, the embedded equipment had poles with green paint that were peeling in multiple areas. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: The chipped paint was scraped and covered with all weather taping. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/17/2025
7. Medium-High risk9/12/2025

   Stairs, exits, etc. unobstructed (3270.91(a))

   The hallway near the toddler room had the exit doors to the outdoor play space that were zip tied and prevented the doors from opening. The left door leading to the outdoor play space towards the front of the building was obstructed by play equipment including bikes and a metal folding chair. Requirement: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed. Correction: Maintenance was informed of the issue on 9/12/2025. They came to inspect the issue and ordered the parts needed to correct the problem. On 9/24/25, they installed a safety latch which has resolved the issue. On 9/15/2025, all bikes, scooters, and toys were removed from both sides of the doorway leading out to the play area. This adjustment freed up space for both staff and children to exit safety through both doors in the event of an emergency. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/24/2025
8. Medium-High risk9/12/2025

   Services proceeded (3270.123(a)(3))

   The files for child #1 and #3 lacked a current child service report updated within the last 6 months. The file for child #2 had child service reports that exceeded 6 months between reports. Requirement: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Correction: Child #1 and Child #3 files have been updated and both folders now have current child service reports. Child #2 now has a current child service report in their folder. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/22/2025
9. Medium-Low risk9/12/2025

   Admission date (3270.123(a)(6))

   The file for child #5 had an agreement that lacked the child's admission date. Requirement: An agreement shall specify the date of the child's admission. Correction: Child #5's start date on the agreement form has been corrected and placed in the appropriate locations on the form. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

   Corrected 9/12/2025
10. Medium-High risk9/12/2025

    Insurance coverage information (3270.124(b)(6))

    The file for child #1 had an emergency contact form that lacked the health insurance policy number. Requirement: 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: Child #1's emergency contact form has been updated and corrected to list the policy number. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
11. Medium risk9/12/2025

    Initial health report for school age; accordance with school attendance (3270.131(a)(4))

    The files for child #4 and #5 lacked an initial health assessment for a school-age child in accordance with the requirements for medical examinations for school attendance in 28 Pa. Code § 23.2 (relating to medical examinations). Requirement: The initial health report for a school-age child must be dated in accordance with the requirements for medical examinations for school attendance in 28 Pa. Code § 23.2 (relating to medical examinations). Correction: Child # 4 and Child #5's folders have been updated with a copy of their school age health assessment forms being placed in their files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/22/2025
12. Medium-High risk9/12/2025

    Infant: updated health report every 6 months/Initial and subsequent health reports (3270.131(b)(1)/3270.182(1))

    The file for child #1, a young toddler, lacked a current health assessment updated within the last 6 months. Requirement: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports. Correction: Child #1's parent was notified that he could not return without updated health assessment form. Updated forms were submitted and child has an appointment on 10/13/25 to receive his 2 year old vaccines. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
13. Medium risk9/12/2025

    Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports (3270.131(b)(2)/3270.182(1))

    The file for child #3, a preschooler, lacked a current health assessment updated within the last 12 months. The file for child #2, a preschooler, had health assessments that exceeded 12 months between assessments. 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. A child's record shall contain initial and subsequent health reports. Correction: Both Child #2 and Child #3's parents have been informed that they must submit updated documentation in order for the child to return. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
14. Medium-High risk9/12/2025

    Exemption documentation from parent/guardian/Dismissal policy (3270.131(e)(1)/3270.131(e)(3))

    The file for child #1, a 2 year old enrolled more than 60 days at the facility, lacked documentation of the 4th DTAP, 3rd HIB, 4th Pneumococcal, and 2nd Hepatitis A vaccinations being administered in accordance with the schedule recommended by the ACIP and lacked exemption documentation. Requirement: The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #1 must be dismissed from care by close of business on 9-12-25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter. Correction: Child #1 parent was notified that he could not return without an updated health assessment form. Updated forms were submitted and the child has an appointment on 10/13/25 to receive his 2 year old vaccines. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
15. Medium-High risk9/12/2025

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

    The files for child #2, #3, and #4 lacked a current emergency contact form and agreement updated by the parent within the last 6 months. 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: On September 22, 2025, the new director had the parents of child #2, #3, and #4 review the emergency contact form and agreement to make sure there weren't any changes that needed updated and then sign the new forms. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/22/2025
16. Medium risk9/12/2025

    Locked cabinet (3270.183(a))

    The child records were observed to be stored in an unlocked filing cabinet in the office. Requirement: Child records are confidential and shall be stored in a locked cabinet. Correction: A new file cabinet was purchased and all staff and children files have been moved to the new locked and secure file cabinet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
17. Medium risk9/12/2025

    Confidential; stored in locked cabinet (3270.193(a))

    The facility persons' records were observed to be stored in an unlocked filing cabinet in the office. Requirement: Facility persons' records are confidential and shall be stored in a locked cabinet. Correction: A new file cabinet was purchased and all staff and children files have been moved to the new locked and secure file cabinet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/15/2025
18. Medium risk9/12/2025

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

    According to the log, the operator did not manually test the interconnected fire detection system in the facility at least once every 30 days between 7-18-25 to 8-18-25. 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: During our staff meeting, everyone was made aware that you have to account for the extra day in months that have 31 days. This covers everyone in the event a staff member is absent the day testing needs to occur. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 9/12/2025
19. Medium-Low risk7/9/2025

    Post the inspection summary (3270.25(b))

    The sanction letter and corresponding inspection summaries were not posted in a conspicuous location used by parents. Requirement: The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected. Correction: As of July 10, 2025, the noncompliance summary letter and inspection summaries have been posted on the parent information board. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/10/2025
20. Medium risk7/9/2025

    Availability of certificate of compliance and applicable regulations (3270.25(a))

    The current certificate of compliance was not posted in a conspicuous location used by parents. Requirement: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office. Correction: As of July 10, 2025. The certificate of compliance has been posted on the parent information board in the front lobby of the child care site Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 7/10/2025
21. Medium risk5/27/2025

    Employed and present 30 hrs/wk (3270.34(c))

    According to the operator, a director has not been employed at the facility since the end of February 2025. As of 5-27-25, the facility has not employed a staff person that qualifies to be the director. Requirement: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week. Correction: The operator has hired a new director and is planning to have all required documents for the director by 6-9-25 to start at the facility. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 6/13/2025
22. Medium-High risk2/28/2025

    Training regarding plan (3270.27(c))

    The file for staff person #5 had emergency plan training that was dated after initial employment at the facility. (See LIS CODE SHEET) 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 person has taken their emergency plan training Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 2/28/2025
23. Medium risk2/28/2025

    Letter to parents (3270.27(e))

    The operator's letter provided to the parent of each enrolled child explaining the emergency procedures lacked the accommodations for infants and toddlers. Requirement: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan. Correction: child's letter to parents was updated and resent out to parents Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 3/4/2025
24. Medium-High risk2/28/2025

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

    The files for staff person #1 and #4 had fire safety training that exceeded a year between trainings. Requirement: Staff persons shall participate, at least annually, in firesafety 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: fire safety training was completed as soon as we noticed it was missing from file Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 2/28/2025
25. High risk2/28/2025

    Comply with CPSL (3270.32(a))

    Staff person #3 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 8-23-18. Staff person #1 had mandated reporter trainings dated 9-4-19 and 10-16-24 that were over 60 months between trainings. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children at a minimum by an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #3, staff person #3 may not work in a child care position at the facility. Correction: mandated reporter training was done immediately Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

    Corrected 2/28/2025