EVERGREEN EARLY LEARNING ACADEMY

Health and Safety Training - Pediatric First Aid and CPR/Exp, educ., training at facility (3270.31(f)(10)/3270.192(2)(iii))

The file for Staff #1 (see IS Code Sheet) contained documentation of first aid and CPR training, but it was not pediatric. Requirement: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: The facility acknowledges that Staff #1's file contained documentation of first aid and CPR training that was not pediatric-specific as required by regulation. To correct this noncompliance, Staff #1 has been scheduled to complete a certified Pediatric First Aid and Pediatric CPR training through an approved training provider. Documentation of the completed pediatric training will be placed in Staff #1's personnel file immediately upon completion. Additionally, all current staff files will be reviewed to ensure that documentation of pediatric first aid and pediatric CPR training is present and current for all staff members as required. Any staff member lacking the appropriate certification will be scheduled to complete the required training promptly. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A director is not employed at the facility, and is therefore, not at the site a minimum of 30 hours per week. 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 facility does employ a Director who oversees the childcare program and is responsible for the overall management and administration of the facility. The program also has designated on-site supervisors present at all times to ensure compliance with regulations, maintain required staffing ratios, support safety procedures, and oversee daily program operations. (Start Date - 2.25.26) To correct this noncompliance, the facility will ensure that documentation and staff scheduling clearly reflect that the Director is present on-site at the facility for a minimum of 30 hours per week, as required by regulation. The Director's schedule will be maintained and documented through staff schedules and timekeeping records to verify compliance. The Director's on-site presence will be monitored to ensure the required hours are consistently met. This correction will be implemented immediately to ensure the facility remains in compliance with Department of Human Services regulations. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physician name, address, phone (3270.124(b)(2))

The Emergency Contact form, in the file for Child #2, did not contain the name of the child's physician or source of medical care. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Correction: information was corrected on site. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The information on how to access the regulations electronically was available for a Group and not a Center. 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: Provider will post the updated information. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written statement (3270.166(1))

The file for Child #5, an infant, did not contain a written formula/feeding schedule from the parent. Requirement: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent. Correction: Provider had parent complete infant feeding schedule. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter/Health assessment, TB test (3270.151(a)/3270.192(3))

The file for Staff #1 did not contain a Mantoux test dated within 12 months of initial employment. 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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis. Correction: Staff member had documentation on file before day of onsite inspection. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Name/address/phone release person (3270.124(b)(7))

The Emergency Contact form, in the file for Child #1, did not include the release person's address. Requirement: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released. Correction: Provider contacted parents during onsite visit and updated the information while inspector was still present in building. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The Emergency Contact form, in the files for Child #3 and Child #4, did not include 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: Parent updated item on site while inspector was on site. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

8th grade + 2 yrs/Exp, educ., training prior to facility (3270.37(b)(3)/3270.192(2)(ii))

The file for Staff #2, who has not yet obtained a high school diploma, lacked verification of two (2) years of experience with children, therefore, not qualifying as an aide/staff member. Requirement: An aide shall have a minimum of an 8th grade education and 2 years of experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Provider has reached out to staff's references, they have agreed to completed hours of verification forms for time staff spent babysitting. Staff completes High school Degree 11/5/2025 and will have Diploma by 12/5/2025. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Admission date/Application, admission, withdrawal dates (3270.123(a)(6)/3270.182(2))

The Agreement, in the file for Child #5, did not specify the date of the child's admission. Requirement: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child. Correction: Item was corrected on site while inspector was present. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Designated release persons (3270.123(a)(5))

The Agreement, in the file for Child #2, did not specify the persons designated by a parent to whom the child may be released. Requirement: An agreement shall specify the persons designated by a parent to whom the child may be released. Correction: provider had parent update the information at pick up that evening. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Arrival/departure times (3270.123(a)(4))

The Agreement, in the file for Child #2, did not specify the child's arrival and departure times. Requirement: An agreement shall specify the child's arrival and departure times. Correction: Item was corrected on site while inspector was present. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Amount of fee (3270.123(a)(1))

The Agreement, in the file for Child #1 and Child #2, did not specify the amount of the fee to be charged. Requirement: An agreement shall specify the amount of the fee to be charged per day or per week. Correction: provider updated the information on site with inspector present. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Refrigerator (3270.107)

The refrigerator, located in the Owls room, contained food debris and was not clean. 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: Provider will deep clean fridge. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

2 feet apart (3270.106(f))

The far left crib in the Owls room, which was occupied, lacked two (2) feet of space on three (3) sides due to a large toy on the floor beside it. Requirement: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use. Correction: Provider removed toy from sleeping area to create safe sleep area for infant. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

In the Orange Bumblebees room, a plastic bag containing stuffed animals/toys, located on the floor, was accessible to children who are still placing objects in their mouths. Tissues were accessible to a young toddler, who is still placing objects in his/her mouth, and the child had it in his/her mouth in the hall and Owls room. In the Owls room, plastic gloves, located on the changing table, were accessible to children who are still placing objects in their mouths. In the Owls room, plastic bags surrounding the diapers, located on a low shelf on the changing table, were accessible to children who are still placing objects in their mouths. 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: Provider has removed plastic bags/plastic gloves from the classroom; all items are stored in plastic bins. Tissues are no longer accessible to children who are still placing objects in their mouths. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Handwashing signs (3270.82(h))

A handwashing sign was not posted at the toilet in the children's restroom. Requirement: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility. Correction: Provider has posted signs above all toilets, diapering areas and sinks. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Has all items (3270.75(c))

The first-aid kit, located in the Orange Bumblebees room, did not contain nonporous gloves. Requirement: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves. Correction: Provider has added gloves to the first aid kit. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Inaccessible to children (3270.75(b))

The first-aid kit and excursion bag containing first-aid items, located in the Owls room, were located on a low shelf, which were accessible to children. The first-aid kit, located in the Gross Motor room, was located on a low shelf, which was accessible to children. Requirement: A first-aid kit must be inaccessible to children. Correction: Provider has purchased wall mounted shelving to remove items from child reach. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Baby wipes, located on the changing table in the Owls room, which stated, "Keep out of reach of children," were accessible to children. Baby wipes, located on the low, diaper rack in the children's restroom, which stated, "Keep out of reach of children," 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: Provider has ordered a wall mounted shelf to move the items up out of child reach. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Aides supervised all times (3270.37(c))

Staff #2 was not supervised by another staff person qualified as an assistant group supervisor, group supervisor, or director, when she was observed to be alone supervising children/taking them for bathroom breaks. Requirement: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor. Correction: Provider now ensure staff is not left alone with children. Inspection: Initial review. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3280.32(a))

The file for Staff #1 did not contain an NSOR Certificate. The file for Staff #2 did not contain an NSOR Certificate or State Police Clearance. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 and Staff #2 may not work in a child care position at the facility. Correction: Staff #1 now has NSOR clearance in file. Staff #2 now has NSOR and State Police Clearance in file. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

HS/GED/Exp, educ., training prior to facility (3280.35(1)/3280.192(2)(ii))

The file for Staff #1 did not contain verification of education or experience. Requirement: A secondary staff person shall have obtained a high school diploma or a general educational development certificate. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Staff now has education and experience verification in staff file. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Protective Outlet Covers 5 yrs. or less (3280.65)

2 protective receptacle covers were missing from electrical outlets, accessible to children five (5) years of age or younger, in the Infant/Young Toddler Room: bottom outlet on left wall and bottom outlet on front wall. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: All outlets now have receptacle covers. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Individual Records (3280.191)

An individual record, for Staff #1 and Staff #2, was not produced at the onsite inspection or electronically, on 8.15.25. Requirement: An individual record is required for each facility person. Correction: All files are now on site at the facility. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).