TRINITY EVANGELICAL LUTHERAN CH

General Health and Safety (3270.21)

Observed in the infant room, a loose crib/pack n play sheet in the rest equipment used by an infant. Requirement: Conditions at the facility may not pose a threat to the health or safety of the children. Correction: Ask parent to buy new sheets that will have a tighter fit. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

Observed staff file #5 who has been employed for more than 90 days (See LIS code sheet), did not contain documentation of completion of the professional development listed in subsection (f)1-10. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Correction: Do not allow that staff member to work until trainings are completed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Observed staff file #1 contained an updated criminal background clearance which was dated more than 60 months after the previous valid criminal background clearance. Observed staff file #1 contained updated mandated reporter training which was dated more than 60 months after the previous valid training. Observed staff file #3 contained updated criminal background clearance, child abuse clearance, and mandated reporter training which were all dated more than 60 months after the previous valid clearances or training. Observed staff file #4 contained CPSL required mandated reporter training which was dated more than 90 days after staff #4 began in a childcare position (See LIS code sheet). Observed staff file #5 contained the NSOR verification letter which was dated after staff #5 began in a childcare position (See LIS code sheet). Observed staff file #5, who has been employed more than 90 days (See LIS code sheet) did not contain documentation of completing the CPSL required mandated reporter training. Observed staff file #6 did not contain a valid NSOR verification letter and staff has started in a childcare position (See LIS code sheet). Observed staff file #6, who had resided outside of Pennsylvania within the previous 5 years, did not contain a Florida Child Abuse clearance. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # -6- may not work in a childcare position at the facility until a valid Florida child abuse clearance is obtained. Correction: Have staff members complete items needed. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #6 has obtained the required out of state clearance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Protective Outlet Covers 5 yrs. or less (3270.65)

Observed an electrical outlet which did not have a protective receptacle cover, on an extension cord next to the refrigerator in the preschool 2 room. Observed in the school age room, in which children age 5 receive care, an electrical outlet which did not have a protective receptacle cover. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: Added covers to those electrical outlets in the listed spaces. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Observed disinfecting wipes, accessible to children in the men's rest room. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Put wipes in locked cleaning cabinet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.66(b))

Observed in the preschool 1 room, cleaning supplies stored on the same shelf as cereal and other food items. Requirement: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces. Correction: Organized shelves for one to hold food items and one to hold cleaning items. 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))

Observed two times in the previous 12 months (7/25/25-8/29/25 and 9/26/25-10/31/25) the fire alarm testing log revealed that the fire alarms were tested more than 30 days apart. 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: I will start to check the fire alarm system, ensuring it gets done every 30 days, not just a day on the calendar. 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))

Observed staff file #2 contained an updated health assessment which was dated 25 months after the previous valid health assessment. 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: Tell staff members 1 year in advance in hopes they can get an appointment closer to the time needing to be seen. Staff #2 has a current valid health assessment at this time. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age appropriate screenings complete (3270.131(d)(8))

Observed child file #2 contained an updated health assessment which did not have a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report. Requirement: A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section. Correction: Not sure how to control the doctor's office to doing their job. But if turned in without what is needed, ask the parents to take back the form and try again. Parents to get the form filled out correctly. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Observed child file #1 contained an updated health assessment which was obtained 13 months after the previous valid health assessment. 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: Continue to give the parents ample warning for any health reports are due. Continue to send reminders on app and then refuse care if health reporter is not turned in. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

Observed a large green block with a peeling cover in the gross motor room. Observed a lego table with a loose leg in the preschool 2 room. 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: Have maintenance fix items and use a protective layer to cover any holes in the play mats. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

Observed the cabinet door under the sink in the preschool 1 room, did not close completely creating a pinch point. 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 tighten the screws so that the clasp would keep the door closed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Observed the most recent documented fire drill was conducted on 1/7/25 which is more than 60 days ago. 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: Did a fire drill with the kids and staff. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Arts and crafts non-toxic (3270.66(e))

Observed shaving cream, labeled "keep out of the reach of children", in the arts and crafts area of the school-age room. Requirement: Arts and crafts materials shall be nontoxic. Correction: Sent shaving cream home with staff member that brought it in and reminded them that we can not use it in the classrooms. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

Observed a spot of frayed carpet in front of the older toddler room entrance door. Observed mulch border anchoring stakes which were sticking up above the mulch border creating a visible 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: Carpet was glued back down. Anchors were hammered back in. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Observed multiple items in the main hallway which were partially blocking the egress. Requirement: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed. Correction: Cleaned up the hallway and put items back where they belonged. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Outdoor equip.- protective surfacing (3270.102(c))

Observed in the outdoor play area with embedded equipment that there were several spots under the slides which did not have the required 9 inches of loose impact absorbing material and were showing torn ground cover material. Requirement: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. Correction: The church members have a work day that they will be adding more wood chips to the playground area. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

All of the following items are labeled "keep out of the reach of children". Observed mineral oil and bleach water accessible to children on a low counter in the young toddler room. Observed hand sanitizer accessible to children in the preschool room. Observed hand sanitizer and sunscreen accessible to children in a low shelf in the learning academy room. Observed bleach water accessible to children on the floor in the indoor gross motor room. Observed hand sanitizer accessible to children on a low shelf in the school-age room. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Put items onto a high shelf and out of the reach of children. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

General Health and Safety (3270.21)

Observed an infant's pack n play which had a loose sheet which was a hazard which increases the infant's risk of SIDS. Requirement: Conditions at the facility may not pose a threat to the health or safety of the children. Correction: Will inform parents the need for new bedding. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Observed staff file #1 contained a child abuse clearance (6/11/19) and an FBI fingerprint clearance (2/27/29) which are both dated more than 60 months ago making them invalid. Observed staff file #2 contained a volunteer criminal background clearance and a volunteer child abuse clearance which are not valid to work in a childcare position. Observed staff file #3 contained a department of education FBI clearance which is not acceptable for childcare employment. Observed staff file #4 contained updated state police and FBI fingerprint clearances which were obtained more than 60 months after the previous valid clearance. Observed facility person #6 did not contain a NSOR verification letter and did not complete the required mandated reporter training. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # -1, 2, 3, and 6- may not work or volunteer in a childcare position at the facility until all required valid clearances are obtained. Correction: Will have staff members complete clearances before returning to work. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Protective Outlet Covers 5 yrs. or less (3270.65)

Observed electrical outlets which did not have protective receptacle covers on an extension cord in the learning academy and in the preschool room. Requirement: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger. Correction: Added outlet covers onto extension cords. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Observed hand sanitizer labeled "keep out of the reach of children" on the windowsill of the school-age room, on a low shelf in the learning academy, and on a low shelf in the older toddler room. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Put all sanitizers out of reach of children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Arts and crafts non-toxic (3270.66(e))

Observed dab o ink bingo daubers which did not have the non-toxic symbol and were labeled "keep out of the reach of children" in the learning academy and in the older toddler room. Observed shaving cream, labeled "keep out of the reach of children", stored with the arts and craft supplies in the learning academy and the preschool room. Requirement: Arts and crafts materials shall be nontoxic. Correction: Throw out non-toxic bingo daubers and keep the ones that are non-toxic. Take all shaving cream out of the classrooms. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

Observed large blocks with peeling covers and exposed foam in the gross motor room. 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: Will cover any exposed areas or will dispose of items. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

Observed a plastic bag accessible to the older toddlers in a low bin in the hallway by their door. 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: Will remind staff to keep items in their bags either child safe or out of the reach of kids. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).