KIDDIE ACADEMY OF LANCASTER

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

On 4/10/26, Staff Person #1 was observed (video footage) caring for children (5 young toddlers) alone on the playground from 10:18am - 10:34am and from 11:0am - 11:08am. Staff Person #2 was hired provisionally and did not have documentation showing that the DHS FBI Clearance had been submitted, as required to begin working with children provisionally, requiring that they be supervised at all times by a qualified staff person. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include completed clearance information required under the CPSL. This includes; a copy of the submission of either the DHS FBI Fingerprint Clearance OR the PA State Police Criminal Record Clearance along with the clearance results of the Child Abuse, NSOR and either the DHS FBI Fingerprint Clearance OR the PA State Police Criminal Record Clearance, Out of state clearances (If lived outside of PA in the past 5 years), and a Disclosure Statement. Tiered LIS: 1. Staff Person #1 may not work in a childcare position at the facility until the results of the DHS Fingerprint Clearance have been received, reviewed and approved to return to a childcare position. 2. The legal entity must arrange for Facility Persons #2 and #3 to attend the in-person "Existing Provider" training. The Operator shall provide a date for when this training will be completed. 3. The legal entity must send all potential new staff files to the certification rep for review and approval prior to the staff persons' start date working with children. New staff files must be sent, reviewed and approved to work, for a period of three months. Correction: The operator will comply with the CPSL and with Chapter 3490 by: -Ensuring provisional employees work within the vicinity of a permanent employee and -Ensuring facility person's record includes completed information as required under the CPSL. Additional tiered plans of correction include: 1. 4/13/26 - Staff member #1 did not work in a childcare position from the date of the visit until the DHS fingerprint clearance was received, reviewed and approved by certification rep, JE, on 5/6/26. 2. 7/17/26 - Facility persons #2 and #3 are registered to attend in-person existing provider training on Thursday, July 16th. Confirmation of registration forwarded to cert. rep and confirmation of completion to be sent upon attending and completing the training on the 16th. 3. 9/1/26 - The legal entity will submit all new staff files to cert. rep for review and approval prior to start date with children for a period of 3 months, beginning June 1, 2026 and ending Sept 1, 2026. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

On 4/10/26, Staff Persons #1 and #2 were on the Playground with their class of young toddlers. Staff Person #2 took a few children inside to change their diapers. When Staff Person #1 later brought the rest of the children inside, one of the children (Child #1), was left alone on the playground. Staff Persons #3 and #4 were on an adjoining playground with prekdg children. Staff Person #3 noticed that Child #1 was left on the playground when the door shut and immediately went to bring Child #1 inside and to the child's classroom to rejoin the group. Child #1 was left unsupervised on the playground for 1 minute. Staff Person #1 was not physically present with the children in their primary care group and left a child unsupervised on the playground. 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 must be supervised at all times. 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. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all facility staff to receive a minimum of two hours of in-person training (and 2 sessions of Technical Assistance) regarding supervision of children with a focus on Primary Care Groups and supervision during transitions. The legal entity must receive DHS approval of the training content prior to scheduling the training. The Operator shall provide a date for when this training and TA will be completed. 3. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children (name-to-face checkmarks, by primary care groups) when transitioning out of one space, at arrival to the new space, at departure and arrival back to the classroom, as documented on the approved tracking sheet (one per primary care group in each classroom daily. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format. Correction: Children on the facility premises and on facility excursions will be supervised by a staff person at all times while maintaining regulated ratio requirements and utilizing primary care group structures. Additionally: 1. 4/13/26 - Children are supervised at all times, and each staff member is assigned a primary care group and is responsible for knowing the whereabouts of those children. The staff person will be physically present with the children in their group while on facility premises or on facility excursions. This took immediate effect at the time of complaint inspection. 2. 8/31/26 - The legal entity is arranging for all staff persons to receive a minimum 2-hour training regarding supervision with a focus on primary care groups and supervision during transitions. This training will be approved by DHS prior to scheduling and will be completed by 8/31/26. 3. 8/31/26 - The legal entity will submit documentation in an already-approved format (transition tracking document) to prove that the facility procedure for counting children (name to face checkmarks, by primary care group) when transitioning out of one space, at arrival to a new space, at departure and arrival back to the classroom, as documented on the approved tracking sheet (one per primary care group daily) is being followed. Documents will be sent to OCDEL weekly for a period of 3 months beginning 6/1/26 and ending 8/31/26. Inspection: Complaints- Legal Location. Source:

Aides supervised all times (3270.37(c))

Staff Person #1 was observed caring for children unsupervised. Staff Person #1 did not have the required childcare experience documented, to qualify as an AGS, therefore Staff Person #1 was qualified as an Aide and was not supervised by an assistant group supervisor. 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: Upon review, it was determined that Staff Person #1 does not currently meet the qualifications for an Assistant Group Supervisor and are appropriately classified as an Aide. Effective 4/8/26, Staff Person #1 was immediately reassigned to ensure she is not left alone with children and is always supervised by a qualified Group Supervisor or Assistant Group Supervisor. Classroom staffing and schedules were reviewed and adjusted to ensure that a qualified staff member is present at all times and that aides are not independently supervising children, including during nap periods. All staff roles and qualifications were reviewed to ensure proper alignment with regulatory requirements. 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))

Staff Person #1 was observed caring for children unsupervised, as an AGS (Assistant Group Supervisor) but did not have 2 years of childcare experience documented in their staff file as required (with a high school diploma/GED) to be qualified as an AGS. 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 childcare experience, education and training prior to service at the facility. Correction: Although documentation of childcare experience was on file, the total documented hours did not meet the required 2,500 hours to qualify Staff Person #1 as an AGS. Effective 4/8/26, Staff Person #1 was immediately reclassified to the role of Aide, which aligns with their current qualifications. Staffing assignments and classroom coverage were adjusted to ensure that Staff Person #1 is supervised at all times, by a qualified AGS or GS. All staff files were reviewed to verify that each employee is appropriately classified based on documented education and experience. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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 training required prior to caring for children unsupervised: Mandated Reporter Training. 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 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 persons available to supervise Staff Person #2, they may not work in a childcare position at the facility. Correction: Upon identification, Staff Person #2 completed the required Mandated Reporter training on 4/28/26. Prior to completion, Staff Person #2 did not work alone with children until the training was fully completed and documented on file. Staff training records were reviewed to ensure all current employees have completed required pre-service training. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No ridicule or threaten harm (3270.113(c))

Staff Person #1 scolded a child and wagged their finger in Child #2's face when the child was playing at the sink and later told Staff Person #2, "I see where (the child) gets it from." Requirement: A facility person may not single out the child for ridicule, threaten harm to the child or the child's family and may not specifically aim to degrade the child or the child's family. Correction: Upon receiving the complaint on 4/7/26, Staff Person #1 was placed on administrative leave. Following a review of the incident, Staff Person #1's employment was terminated. Classroom expectations regarding positive guidance and interactions with children were reviewed with all staff, focusing on treating all children and their families with equity and respect. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Promote development (3270.111(c))

Staff Person #1 noticed that Child #1 had a different shirt on after taking the child to the bathroom. When coming out of the bathroom with the child, Staff Person #1 yelled at Staff Person #3 "Don't put that shirt on" Child #1! "You do that all the time!" Staff Person #3 said that it was the t-shirt the child was wearing under a sweater and that the sweater was taken off because the child was hot. Staff Person #1 walked over and grabbed the shirt off of Child #1 and Staff Persons #1 and #2 began arguing and calling one another disrespectful. This occurred in front of the other children, staff and a parent who was picking up their child. Requirement: Daily activities shall promote the development of skills, social competence and self-esteem. Daily experiences shall recognize the child as an individual and give some choice of activities that respect personal privacy, lifestyle and cultural background. Staff Persons #1, #2 and #3 must complete the following online training through Better Kid Care: * Big Emotions and Self-Regulation for Adults and Children (2 hours) * Ethics: A Guide for Professional Behavior (2 hours) Correction: Upon receiving the complaint on 4/7/26, Staff Person #1 was placed on administrative leave. Following a review of the incident, Staff Person #1's employment was terminated. Staff Persons #2 and #3 completed the directed training on 4/21/26 - 4/23/26 focused on appropriate guidance strategies, maintaining respectful communication, and supporting children in a positive and developmentally appropriate manner. Classroom expectations regarding developmentally appropriate interactions with children and coworkers, were reviewed with all staff. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Small Toys and Objects (3270.103)

Diapers and wipes in plastic bags, were found to be accessible to children in a low, storage unit with drawers, in the 2's Rm. 1 bathroom (Corrected on-site). 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: Upon receiving the citation, the diapers and wipes in plastic bags were immediately moved to an area inaccessible to children. They are now stored in a locked cabinet out of reach of children. All classrooms were reviewed to ensure that all items that could pose a risk are stored out of reach of children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

The file for Staff Person #1 did not include two written, nonfamily references 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: Staff Person #1 is no longer employed at the facility as of 3/27/2026. Current staff files have been reviewed to ensure all employees have 2 written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter/Mantoux TB (3270.151(a)/3270.151(c)(2))

The file for Facility Person #1 did not include an initial health assessment and TB test results, conducted within 12 months prior to providing initial service at the facility. 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. 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 Person #1 is no longer employed at the facility as of 3/27/2026. Current staff have been reviewed to ensure all employees have received a health assessment and TB test at initial employment as required. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written instructions (3270.133(2))

Children #1 and #2 had medication that did not have written instructions from the individual who prescribed the medication. Requirement: A staff person shall administer a prescription medication only if written instructions are provided from the individual who prescribed the medicine. Instructions for administration contained on a prescription label are acceptable. Correction: On 3/26/2026, both medications were immediately sent home with the families. Medication for Child #1 was returned to the facility in its original, properly labeled container, with the prescriber's instructions on the prescription label, and is now compliant. Medication for Child #2 has not been returned to the facility. The child does not currently have medication on site. All remaining medications were reviewed to ensure they are in original containers with proper labeling, including written instructions from the individual who prescribed the medication. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container/Name on bottle (3270.133(1)/3270.133(3))

Medications (inhalers) for Children #1 and #2, were not in the original container that identifies the name of the medication and the name of the child for whom the medication is intended. 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. The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container. Correction: On 3/26/2026, both medications were immediately sent home with the families. Medication for Child #1 was returned to the facility in its original, properly labeled container and is now compliant. Medication for Child #2 has not been returned to the facility. The child does not currently have medication on site. All remaining medications were reviewed to ensure they are in original containers with proper labeling. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Updated every 6 months/Dated signature affixed (3270.124(f)/3270.181(d))

The Emergency Contact Forms for Children #3 and #4, did not have the enrolling parent's dated signature at the bottom, showing the date that the form was completed and reviewed. Without this, there is no way of knowing if it was on file (and in the children's classroom) when the children started attending and thereby indicating when the forms need to be updated in 6-months. Requirement: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. Following review, a parent shall attest to the accuracy of information in the emergency contact information and the financial agreement at each review by affixing a dated signature to the record. Correction: The parents of Children #3 and #4 reviewed, signed and dated their child's emergency contact form the following day on 3/27/2026 and updated forms were placed in the children's files and a copy was distributed to the children's classrooms. A review of all children's files was conducted to ensure all emergency contact forms are complete and signed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

A net tent in the cozy area of the 3's Rm. 2, was torn and had holes in the netting (Corrected on-site). The walkway that the 2-year-olds use to get to the playground, had 2 small sensory bins that were dirty, with standing water and debris. 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: Upon receiving the citation, the cozy area tent was immediately removed from the room on 3/26/2026. All classrooms were inspected by Administration to ensure that equipment is in good repair and free of hazards. The sensory bins were cleaned and removed from the walkway to the playground. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

Diaper creams/ointments were found to be accessible to children in the 2's Rm. 1, located in a plastic bin drawer unit in the bathroom (corrected on-site). Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Upon receiving the citation, the diaper creams/ointments were immediately moved to an area inaccessible to children. They are now stored in a locked cabinet out of reach of children. All classrooms were reviewed to ensure that all items that could pose a risk are stored out of reach of children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The file for Facility Person #1 did not include documentation of initial training regarding the emergency plan, within 90 days of starting. 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 #1 is no longer employed at the facility as of 3/27/2026. Current staff have been reviewed to ensure all employees have received emergency plan training as required. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

Staff Person #1 did not have two, written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person, as required prior to working with children. 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: Staff Person #1 did not have two written, nonfamily references on file as required. The missing references were obtained on 3.20.26 and placed in the staff file. An immediate review of all staff files was conducted to ensure all employees have the required two written, nonfamily references on file. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exp, educ., training prior to facility/Transcript, diploma and letters (3270.192(2)(ii)/3270.192(2)(iv))

Staff Person #1 did not have documentation of education and experience prior to working. Requirement: A facility person's record shall include verification of childcare experience, education and training prior to service at the facility. Acceptable verification of experience, education or training is a transcript or a diploma, or a letter signed by a representative of the experiential, educational or training entity. Correction: The missing documentation to verify Staff Person #1's education was obtained on 3.20.26 and placed in the staff file. An immediate review of all staff files was conducted to ensure all employees have required education documentation on file. 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))

Staff Person #1 did not have an initial health assessment and TB test results completed within 12 months prior to working with children at the facility. 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: Upon receiving the citation, Staff Person #1 was immediately removed from working in a childcare position on 3.19.26 upon identification that a completed health assessment and TB test results were not on file. Staff Person #1 will not return to work in any capacity involving children until a completed and compliant health assessment and TB test results are obtained and placed in the staff file. An immediate review of all staff files was conducted to ensure all employees have completed health assessments on file as required. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Staff Person #1 was observed working with children and did not have documentation of the required clearances to be hired provisionally. Staff Person #1 did not have completed out-of-state clearances or a completed NSOR clearance Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Staff Person # 1 may not work in a childcare position at the facility until all clearances are received and on file. Correction: Upon receiving the citation, Staff Person #1 was immediately removed from working in a child care position on 3.19.26 upon identification of missing required clearances. Staff Person #1 will not return to work in any capacity involving children until all required clearances, including out-of-state clearances and NSOR clearance, are completed and on file. An immediate review of all staff files was conducted to ensure all other employees have complete and compliant clearance documentation. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

Staff Person #6 did not have documentation of two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. There was just one reference on file. 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: Upon citation, the facility obtained a second written, nonfamily reference for Staff Person #6 the following day. The reference attests to the individual's suitability to serve as a facility person. The additional reference was placed in the staff member's personnel file and submitted to DHS Certification for review. Staff Person #6's file now contains the required two written, nonfamily references. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

46 or more children- additional group sups/Group sup present 30 hrs (3270.35(e)/3270.35(f))

Based on the center's current enrollment (76 children), two Group Supervisors are required. There was only 1 Group Supervisor (Staff Person #2) employed at the facility and working 30+ hours per week, who had the required education (degree with transcript)/experience documented in their staff file. Staff Persons #3, #4 and #5 did not have transcripts that documented what their degree was in or the number of credits they have in approved human services/education to determine if they were qualified as a Group Supervisor. Requirement: In a facility in which more than 45 children are enrolled, a group supervisor is required for the first group of 45 enrolled children and for each group or partial group of 45 additional enrolled children. Each additional group supervisor shall be employed by and be present at the facility for a minimum of 30 hours per week. Correction: Upon citation, the facility immediately reviewed the qualifications of staff assigned to Group Supervisor positions. Documentation confirming that Staff Person #4's degree/credits meets the qualifications for a Group Supervisor, was obtained and submitted to DHS Certification for review. DHS has since confirmed that Staff Person #4's degree qualifies them as a Group Supervisor. Updated transcripts and documentation have been placed in the staff file. The facility now employs two qualified Group Supervisors (Staff Person #2 and Staff Person #4) who meet the education and experience requirements for the current enrollment of 76 children. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Staff Person #6 had clearances that included a criminal record that had not been sent to DHS Certification for review. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Correction: Upon receiving the citation, the criminal history clearance for Staff Person #6 was immediately submitted to the DHS Certification Office for review. Documentation of the submission has been retained in the employee's personnel file. The staff member will not be permitted to work unsupervised while DHS reviews the criminal history and confirmation has been received that the clearance has been reviewed and approved by DHS Certification. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times /Staff assigned to specific children (3270.113(a)/3270.113(a)(1))

Staff Persons #1 and #2 left Child #1 unattended on the playground for 10 minutes before realizing that the child was not with the group in the Play Room, after coming indoors from the playground. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all facility staff to receive a minimum of two hours of in-person training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date for when this training will be completed. 3. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children and supervising specific children in primary care groups, is followed at all times (daily name-to-face 30 minute/times of transitioning count sheet by primary care group). The legal entity will confirm continuing compliance by sending copies of the documentation to the certification representative on a weekly basis for a period of three months after DHS approves the documentation format. The correction date for this portion of the plan shall be at minimum 3 months from the date the checklist is approved and completed correctly. Correction: Tier 1 -- Immediate Supervision Correction Effective immediately, children are supervised at all times. Staff assignments were clarified the same day as the incident, so that Staff Persons #1 and #2 worked in separate rooms, supervised at all times, until the Safety Plan in place was lifted. Staff were instructed that each staff person is responsible for the supervision of specific children at all times, including during transitions and outdoor play. Head counts are required before leaving the classroom, upon arrival at the playground, before leaving the playground, and upon re-entry to the classroom. The Director immediately reinforced that staff must maintain physical presence and continuous sight and sound supervision of their assigned group. Tier 2 -- Correction date: 1/13/26 Required In-Person Supervision Training - The legal entity will arrange for a minimum of two (2) hours of in-person supervision training for all facility staff by a STARS coach. The training will focus on: -Active supervision -Assignment of responsibility for specific children -Name-to-face counts -Transition supervision -Playground safety and accountability The training has been scheduled for 1/13/26 and all staff are required to attend. Attendance documentation and training materials will be maintained on file and made available to DHS. Tier 3 -- Correction date: 2/27/26 Documentation of Supervision Procedures: The legal entity will implement a daily name-to-face supervision checklist, completed every 30 minutes and during all transitions, organized by primary care group. The DHS-approved checklist will document: Child name Child arrival & departure time Time of count Count of children in primary care group Count of total children in the room Staff person responsible Staff initials/signature The daily checklists (by primary care group in each classroom) will be collected every Friday at closing, reviewed for accuracy, and emailed to the certification rep every Monday for the week prior, for a 3-month period. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

General Health and Safety/Promote development (3270.21/3270.111(c))

Staff Persons #1 and #2 admittedly drank alcohol on their lunch break, then returned to work, caring for children in the same classroom. It was reported that, on one occasion, Staff Person #1 came into a classroom talking very loudly and grabbed Staff Person #3 by the neck. This was in the presence of children during naptime. On another occasion, it was reported that Staff Person #1 came into a classroom during naptime, turned on the lights and seemed "more than tipsy" and was loud and giggly. Staff Person #1 told Staff Persons #3 and #5 that they drank on their lunch break. Staff Persons #4 and #5 were aware that Staff Person #1 appeared visibly intoxicated while caring for children at the facility and did not immediately take action to ensure the health and safety of children in care. Requirement: Conditions at the facility may not pose a threat to the health or safety of the children. Daily activities shall promote the development of skills, social competence and self-esteem. Daily experiences shall recognize the child as an individual and give some choice of activities that respect personal privacy, lifestyle and cultural background. TIERED LIS: 1. Children must be supervised at all times and staff may not be under the influence of alcohol at any time while caring for children. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a staff policy regarding alcohol/drugs that includes the following at a minimum: * Zero tolerance for the use of alcohol/drugs before and during caring for children * No alcohol on the premises at any time * Supervision of children expectations * Staff responsibility to report to admin any evidence of or suspicion of staff being incapacitated or under the influence of alcohol or drugs (not including prescribed medications taken as prescribed) The policy must be sent to certification rep for approval. 3. The legal entity must arrange for all staff to be trained on this policy and must provide the date of the training to the certification rep, along with documentation showing that all staff were trained. The policy must be added to the staff handbook and discussed during new staff orientation/onboarding. Correction: Tier 1 - Immediate Correction Effective immediately, the legal entity has reaffirmed and enforced the requirement that all children are supervised at all times by alert, capable staff, and that no staff member may be under the influence of alcohol while caring for children. Staff Persons #1 and #2 were terminated. Administration met with Staff Persons #3, #4, and #5 to discuss the need to report drug/alcohol use while working, immediately moving forward. On 12/17/25, administration met with all staff on duty to review supervision expectations and to clearly communicate that any use of alcohol before or during work hours is strictly prohibited. Staff were reminded of their responsibility to ensure a safe, responsive environment that supports children's development, emotional safety, and individual needs. Any staff member suspected of being impaired will be immediately removed from child supervision duties and addressed in accordance with personnel policies. Tier 2 - Correction date: 12/17/25 The legal entity revised the Alcohol and Drug Policy that includes, at a minimum, the following components: - Zero tolerance for the use of alcohol or illegal drugs before or during caring for children - No alcohol permitted on the premises at any time, regardless of event or circumstance - Clear expectations for active supervision of children at all times - Staff responsibility to immediately report to administration any evidence or reasonable suspicion that another staff member may be incapacitated or under the influence of alcohol or drugs (excluding prescribed medications taken as directed by a licensed medical provider) The policy will be written in clear, professional language, reviewed internally by administration, and submitted to the certification