RAINBOWS END CHILD ACADEMY

Staff assigned to specific children (3270.113(a)(1))

Based on the facility's self-reported noncompliance and staff statements, it was determined that on April 6, 2026, Staff Persons #1, #2, and #3 conducted an excursion with 12 children (3 young toddlers and 9 older toddlers) to the Garden room located at the Carnegie Library of Pittsburgh - Squirrel Hill. At approximately 11:40 a.m., the group departed the Garden room and returned to the facility at 12:00 p.m. Upon arrival at the facility, Staff Persons #1, #2, and #3 then realized Child #1 was not present and was left behind at the library alone and unsupervised without a staff person physically present. Requirement: 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. Correction: Each person will continue to receive a group of children to be responsible for. The staff person will receive tags and complete a name-to-face check immediately. The Director will conduct random supervision checks to ensure the systems are being utilized appropriately. As part of the new supervision policy, when leaving the facility to go to a secondary location all staff are required to call in to the director with a headcount upon arrival and prior to departure of that location. The staff must also utilize the name-to-face check in system. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

Based on the facility's self-reported noncompliance and staff statements, it was determined that on April 6, 2026, Staff Persons #1, #2, and #3 conducted an excursion with 12 children (3 young toddlers and 9 older toddlers) to the Garden room located at the Carnegie Library of Pittsburgh - Squirrel Hill. At approximately 11:40 a.m., the group departed the Garden room and returned to the facility at 12:00 p.m. Upon arrival at the facility, Staff Persons #1, #2, and #3 then realized Child #1 was not present and was left behind at the library alone and unsupervised. 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. Tiered LIS: 1. Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. 2. The Operator will collaborate with ELRC 5 to develop and implement a tangible identification system for each staff to identify the specific children in their respective supervisory groups, and for tracking children during transition periods. The selected identification system must be submitted to the Western Regional Office for review. All staff will utilize the identification method appropriately at all times while supervising children for a minimum of 3 months from the date the system is submitted for review. The correction date for this portion of the plan shall be at minimum 3 months from the date the selected system is submitted to the Western Regional Office. 3. The operator will require all staff persons at the facility to complete a training regarding Ratio, Active Supervision, and the implementation of the selected identification system. The training must be offered by ELRC 5, in-person and a minimum of 2 hours. The training must be completed within 4 months of the approval of this plan of correction. The training must be approved by the Department prior to implementation. Upon completion of the training, staff training documentation will be provided to the OCDEL-DHS representative by email. The training may count towards the mandatory 12 training hours required by the Department. The operator shall provide a date for when this training will be complete. Correction: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. 1. 4/6/26 Children on the facility premises and on facility excursions off the premises shall be always supervised by a staff person. Staff persons 1-3 were immediately required to retake the supervision training. 2. 9/30/26 The Operator will collaborate with ELRC 5 to develop and implement a tangible identification system for staff to identify the specific children in their respective supervisory groups, and for tracking children during transition periods. The selected identification system will be submitted to the Western Regional Office for review. All staff will always utilize the identification method appropriately while supervising children. 3. 10/30/26 All staff persons at the facility, including the Director, will complete a training regarding Ratio, Active Supervision, and the implementation of the selected identification system. The training will be offered by ELRC 5, in-person and a minimum of 2 hours. The training will be approved by the Department prior to implementation. Upon completion of the training, staff training documentation will be submitted to the OCDEL-DHS representative by email. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

In the Gym, a children's soft climbing block was observed to be torn and not in good repair. In the OT/PS room, a plastic lid was observed to be cracked with sharp corners and not in good repair. 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 soft climbing block was removed. The cracks in the plastic lid were repaired. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB (3270.151(c)(2))

The file for Staff Person #3 contained documentation of TB screening results dated 10/20/25 but was not at initial employment (See LIS Code Sheet). Requirement: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. Correction: The file for staff person #3 was updated with documentation of tb screening. Inspection: Renewal. 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 two most recent health assessments in the file for Staff Person #1 are dated more than 24 months apart: 1/18/23 and 3/19/25. 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 health assessments in staff files will be dated within 24 months of the previous assessment date. The staff person's file is now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each child care space (3270.124(c))

Emergency contact information for child #2 was not present in the Gym where the child was observed to be receiving care. Emergency contact information for child #3 was not present in the Infant room where the child was observed to be receiving care. Requirement: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space. Correction: Emergency contact forms for child #2 was placed in the folder in the gym, and a copy of the emergency contact form for child #3 was placed in the Infant room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Parent home/work address, phone (3270.124(b)(3))

The emergency contact form in the file for child #1 lacked the enrolling parent's work telephone number. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: The work telephone number for enrolling parent of child #1 was added on the emergency contact form. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Refrigerator (3270.107)

The refrigerator in the Infant room lacked an operable thermometer. 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: A thermometer was placed in the infant room refrigerator. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A children's wooden bench was obstructing an exit door from the Infant room to the YT room. Requirement: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed. Correction: The wooden bench obstructing the exit door from the infant to the YT room was removed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The files for Staff Persons #1, #2, #5, #6 contained documentation of written evaluations dated more than 12 months apart. The file for Staff Person #4 did not contain documentation at the time of inspection of a written evaluation within the last 12 months. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: We will ensure that written evaluations are updated every 12 months. An evaluation was completed and placed in staff person's #4 file. The files for Staff Persons #1, #2, #5, #6 are now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The file for Staff Person #2 contained documentation of FBI clearance results dated 10/14/19 and 12/11/24, which is more than 60 months apart. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: We will ensure that FBI clearance results are obtained no more than 60 months apart, or staff removed if not done and documentation of that put in the file. The staff person's file is now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The file for Staff Person #4 contained documentation of emergency plan training on 5/3/24 and 6/20/25, which is more than 12 months apart. 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: The file for staff persons containing documentation for emergency plan training will be updated within 12 months. The staff person's file is now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file for Staff Person #1 contained documentation of PA State Police clearance results with a Record for Control but lacked the corresponding Rap Sheet within 45 days of hire (See IS Code Sheet) as required for provisional hiring under the CPSL. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1 may not work in a child care position at the facility. Correction: Staff Person #1 was removed from child care facility. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each staff person meets quals/Exp, educ., training prior to facility (3270.33(a)/3270.192(2)(ii))

The files for Staff Persons #1, #2 and #3, identified as assistant group supervisors, lacked qualification documents for the position in which the staff persons are performing. Requirement: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Verification of child experience was obtained and placed in employees' files. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

The file for Staff Person #3 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person. 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: Non family reference was obtained for staff person #3 and placed in their file. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The files for staff persons #1 and #2 did not contain documentation of NSOR clearance results prior to date of hire (See IS Code Sheet) as required under the CPSL. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Staff persons 1 and 2 were removed from classrooms. Staff #2 had given notice of resigning their position prior so did not return and is no longer employed at the facility. Staff #1 was reinstated once NSOR was received. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

CPSL information (3270.192(4))

The files for staff persons #1 and #2 did not contain documentation of NSOR clearance results prior to date of hire (See IS Code Sheet) as required under the CPSL. Requirement: 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. Facility Person #1 and #2 may not work in a child care position at the facility. Correction: Staff persons 1 and 2 were removed from classrooms. Staff #2 had given notice of resigning their position prior so did not return and is no longer employed at the facility. Staff #1 was reinstated once NSOR was received. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Similar Age Level (3270.51)

On 5/21/25 at approximately 9:40am in the Older Toddler room, staff person #1 identified 9 older toddlers in their assigned group of children. At approximately 9:45am in the Preschool room, staff person #3 identified 18 preschool-aged children in their assigned group of children. Requirement: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. Tiered LIS: 1. The required staff:child ratios must be maintained at all times. 2. Within 60 days of the approval of this plan of correction, the Legal Entity will ensure the director arrange all staff persons, including the Legal Entity to attend a minimum of two hours of in-person training conducted by the ELRC on ratio and supervision. The training is titled Creating a Safe Environment Through Active Supervision. The two hours of training will be counted towards staff person's annual clock hours. 3. The Legal Entity will ensure the director partner with the ELRC to develop a Staff Coverage Schedule that includes designated lunch and restroom times based on staff shifts and ratio needs. Breaks will be scheduled to maintain required staff-to-child ratios, with floaters or designated staff providing coverage. Staff must remain in childcare spaces until properly relieved. The schedule must be posted in all childcare spaces, and all breaks will be documented in a log. The director will review the schedule and log weekly for 3 months to adjust for any staffing or enrollment changes. Documentation will be made available to OCDEL upon request. 4. The Legal Entity will ensure the director develops and implements a hands-free child tracking system to support classroom coverage and maintain appropriate staff-to-child ratios. The director will conduct walk-throughs twice daily to ensure staff are using the system appropriately and remaining in designated childcare spaces. 5. The Legal Entity will ensure the director holds 2 monthly staff meetings following the meeting with the ELRC. Topics will include the structured break schedule, restroom procedures, maintaining staff-child ratios, use of the break log, roles of temporary staff, floaters, and permanent staff, and proper use of the child tracking system. Inspection summaries issued within the last six months will also be reviewed. Each meeting will include a dated agenda and a signed attendance sheet. All documentation will be made available to OCDEL upon request. Correction: Ratios were restored once each of the additional staff assigned to be with staff #1 and staff #3 returned from the bathroom and from opening the back door. 1. Another staff went to assist in the room with Staff Person # 1 to ensure that staff-child ratios are adhered to. Floaters will be assigned to classrooms at different intervals daily to allow staff to take bathroom breaks and will step in for staff taking breaks until they return. POC Due Date: _5/21/2025___ 2. All staff and the Owner/Director will complete two hours of in-person training conducted by the ELRC on ratio and supervision. POC Due Date: 8/5/2025_____ 3. A staff coverage system has been created and implemented to ensure that lunch and restroom breaks are covered so that ratios are adhered to. The schedule will be posted in all childcare spaces. A break log has been created for staff to document all breaks. The director will review the schedule and break log each week for 3 months and make adjustments as needed. POC Due Date: _10/24/2025__ 4. A hands-free child tracking system to support classroom coverage has been developed and is being implemented and owner/director are conducting walk-throughs twice daily t

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

Staff person #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Health and Safety training and Pediatric First Aid/CPR. 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. Until such time as the required pre-service trainings are completed, staff person #-2 must be supervised by a AGS who has completed the required trainings related to this citation. If there are no staff persons available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility. Correction: Other staff assigned to the room were advised to have a floater step in the classroom before leaving the class when staff #2 is in the classroom with them. A floater who has completed the required pre-service trainings went into the room to assist and supervise staff person #2. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No physical punishment (3270.113(b))

According to staff statements, on 3-17-25, staff person #1 was observed hitting an infant child on the back of the head. Requirement: A facility person may not use any form of physical punishment, including spanking a child. Correction: Staff person #1 was dismissed. Her employment was terminated immediately. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mixed Age Level (3270.52)

On 10/4/24 at approximately 8:45am, staff person #1 and 10 children were observed in the OT Room. Staff person #1 named 7 older toddlers, 2 young toddlers, and 1 preschool age child that was in their assigned group of children. Requirement: *When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The required staff:child ratios must be maintained at all times. Correction: Another staff stepped into the group to supervise the children and to ensure that child/adult ratios are maintained. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Based on staff interviews, on 9/25/24 at approximately 12:00pm, staff person #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Pediatric first aid/CPR and Health and Safety. 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. Until such time as the required pre-service trainings are completed, staff person #2 must be supervised, when interacting with children, by an AGS who has completed the required trainings related to this citation. If there are no staff person(s) available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility. Correction: Another staff person who is an AGS and has completed the required trainings stepped in to supervise staff #2. Staff person #2 was removed from care until Pediatric first aid/CPR and Health and Safety training is completed. Inspection: Unannounced Monitoring. 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 person #2 did not include documentation of a health assessment conducted at 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 was removed from caring directly for children until they could obtain an adult health assessment. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB (3270.151(c)(2))

The file for staff person #2 did not include documentation of a TB screening at initial employment. Requirement: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. Correction: Staff was removed from caring directly for children until they could obtain a TB test. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

The front doors to the entrance of the facility do not work properly as the electronic buzzer does not unlock the door granting immediate access. 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: The front entrance was working properly, however, the buzzer to allow people in was broken. A technician was called in to repair the buzzer. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).