ESTELLE S CAMPBELL BOYS & GIRLS CLUBHOUSE

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

*SECOND VIOLATION The facility's fire detection system has not been tested within the last 30 days. The most recent testing observed on file at the time of inspection was dated 11/26/25. Previously cited on SIN-00277844 on 11/12/25. 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: Moving forward we will ensure that the fire detection system is tested before the 30 day window is up. The fire detection system has been tested. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The files for Staff Persons #1, #2, #3, #4, #5, #6, and #10 lacked documentation of emergency plan training within the last 12 months. The files for Staff Persons #7, #8, #9, and #11 lacked documentation of emergency plan training at initial employment (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: Moving forward we will assure that each facility person receives training regarding the emergency plan at the time of employment and on a annual basis and will be kept in each file. All staff persons will receive emergency plan training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

The file for Staff Person #8 contained documentation of FBI clearance results dated 7/2/25 but was after the staff person's date of hire (See LIS Code Sheet). The file for Staff Person #8 is now current. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Moving forward we will make sure that all clearances are done before the staff person's date of hire. To comply with CPSL and Chapter 3490. The file for Staff Person #8 is now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e)(4)(i))

The file for Staff Person #10 contained documentation of pediatric first aid/CPR training that was not renewed prior to the expiration date of the most current certification on file. Requirement: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Correction: Boys and Girls Club will contain documentation of staff persons #10's Pediatric CPR training. The file is now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The two most recent fire safety trainings in the files for Staff Persons #1, #3, #6 and #10 are dated more than 12 months apart. The files for Staff Persons #2, #4 and #5 have not had fire safety training within the last 12 months. The file for Staff Person #8 contained documentation of fire safety training dated 10/21/25 but was not within 12 months of hire. 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. Correction: Moving forward, staff members will participate annually in a fire safety training conducted by a fire professional. The files are now current for Staff Persons #1, #3, #6, #8 and #10. Staff Persons #2, #4, and #5 will complete fire safety training. 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 #11 did not contain documentation of valid PA State Police clearance results within 45 days of hire (See LIS CODE SHEET). The PA State Police clearance results on file did not contain the disseminated dated, resulting in the clearance to be invalid. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #11 may not work in a child care position at the facility. Correction: Moving forward, we will ensure that all staff personnel clearances are completed before hire. Staff Person #11 was removed from a child care position until the requirement clearance results are submitted and verified. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The two most recent written evaluations in the files for Staff Persons #1, #3, #4, #5 are dated more than 12 months apart. The file for Staff Person #2 lacked documentation 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: Director tracks evaluations on the staff data sheet and ensure that they are within the 12-month window. Staff Persons #1, #3, #4, #5 are now current. A written evaluation will be completed and filed for Staff Person #2. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Contaminated trash in closed plastic-lined receptacle (3270.67(d))

Trash that was contaminated by human secretion was observed contained in a lidded trash receptacle but was not plastic-lined in the Cafeteria. Requirement: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. Correction: The trash receptacle in the Cafeteria will be a hands-free, plastic-lined with a closed lid. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Good repair (3270.72(c))

A window screen in the Preschool room was observed to be torn and not in good repair. Based on staff statements, the staff open the window for ventilation. Requirement: Screens shall be in good repair. Correction: Director spoke to the Director of Facilities, and a new screen was purchased. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Has all items (3270.75(c))

The first aid kit in the Preschool room did not contain soap and scissors. 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: Soap and scissors were added to the first aid bag. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Handwashing signs (3270.82(h))

A handwashing sign was not posted at one toilet in the boy's restroom located next to the cafeteria. Handwashing signs were not posted at two sinks and two toilets in the girl's restroom and at one sink in the boys's restroom located next to the Arena. 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: Handwashing signs have been put up in the boys and girls restroom. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Posted in group space (3270.111(b))

A written plan of daily activities was not posted in the Makers Space and Game room. Requirement: The written plan of daily activities shall be posted in the group space. Correction: Moving forward, we will ensure that we have written activity plans for the MakerSpace and Game room. Daily activities were posted in the rooms. Inspection: Renewal. 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 #1 lacked documentation of the name and address of the child's physician. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Correction: We will contact the child's mother and receive the physician's information. The form will be updated. 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 documentation of the enrolling parent's work telephone number. The emergency contact forms in the files for Children #2 and #3 lacked documentation of the enrolling parent's work address and telephone number. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: We will reach out and get all parents' work addresses and telephone numbers. Forms will be updated. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each child care space (3270.124(c))

Emergency contact forms were not present in the Preschool room where children were observed 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: We will ensure that the bookbag with the emergency contacts is in the bookbag at all times. The emergency contact forms for children receiving care were placed in the room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.133(1))

The first aid bag in the Preschool room was observed to contain a child's epi-pen that was not in the original container. Requirement: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received. Correction: Moving forward, we will require that parents are to provide the original box for medication and fill out a medication log. The original container was obtained from the parent and placed in the first aid bag. 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 files for Staff Persons #1, #2, and #10 are dated more than 24 months apart. The file for Staff Person #4 lacked documentation of a health assessment conducted within the last 24 months. The files for Staff Persons #5 and #11 contained documentation of a health assessment but were not at initial employment (See LIS Code Sheet). 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: Moving forward, the director will ensure that everyone's health assessments are completed at initial employment and then every 24 months. Staff Person #4 will have a health assessment completed and submitted. The remaining staff files are now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB (3270.151(c)(2))

The files for Staff Persons #5 and #11 contained documentation of a TB screening 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: Making sure that the adult health assessments include the TB screening upon initial employment. The files for Staff Persons #5 and #11 are now current. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Potentially hazardous food refrigerated (3270.161(d))

Children's lunchboxes that contained potentially hazardous foods (cheese, yogurt) were observed stored on top of the children's cubbies and were not refrigerated in the Preschool room. Requirement: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated. Correction: Moving forward, staff will ensure all lunches are refrigerated. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(6))

The facility's files contained documentation of conducting emergency drills on 12/22/23 and 11/5/25, which is more than 12 months apart. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: Moving forward we will ensure that the emergency drills are conducted annually. We will make sure that all are documented and on file here at ESC. Will put on Google Calendar to ensure it gets done annually Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The facility's documentation of conducting fire drills was observed to exceed 60 days between drills conducted on 2/27/25 and 5/14/25. Requirement: The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days. Correction: Moving forward, the Director or designated staff person will ensure that fire drills are conducted at least once every 60 days. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Hypothetical locations (3270.94(a)(4))

The hypothetical location for the fire drills conducted on 7/27/25 and 8/11/25 was the same and was not rotated around the facility for each drill. Requirement: The Director or designated staff person who is responsible for compliance with this chapter ensure the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills. Correction: Moving forward, we will make sure that each time a fire drill is done that it is in a different hypothetical location. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Participation (3270.94(a)(7))

The facility's fire drill log did not include the names of the facility persons in attendance during the fire drills conducted 5/14/25 through 10/18/25. Requirement: The Director or designated staff person who is responsible for compliance with this chapter ensure facility persons and children in attendance participate in the fire drill. Correction: Making sure that all facility personnel who are in attendance for the fire drill, their names are marked on the sheet. 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))

The facility's fire detection system has not been tested within the last 30 days. The most recent testing observed on file at the time of inspection was dated 3/27/25. 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: We will make sure that we are keeping up with the 30-day testing period. Ensuring the system is being tested. The fire detection system was tested on 11.12.25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(f))

The facility's files did not contain documentation of sending the emergency plan updates to the local municipality and county EMA. Requirement: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency. Correction: This was sent to our DHS Rep on 11//24/25 by our COO. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).