LITTLE STARS CHILD CARE LLC

Two written references (3270.192(5))

Staff #1 was observed in direct care with children on 5/1/26 and as of this date did not have 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: Two written non-family references letter was immediately requested and placed on staff's files on 05/02/2026 the two letters were received the next day and were placed on the staff file Inspection: Allocated Unannounced Monitoring. 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))

Staff #1 was observed in direct care with children on 5/1/26 and as of this date did not have proof of a health assessment and TB screening conducted within 12 months prior to providing initial service in a childcare setting. 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: A health assessment and TB screening was conducted on 05/02/2026 for staff #1 a Mantoux test result was received negative on 05/05/2026. Health assessment for staff # 1 is on file at the center upon request. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Staff #1 was observed in direct care with children on 5/1/26 and as of this date did not have proof an 8th grade education and 2 years of experience with children. Requirement: An aide shall have a minimum of an 8th grade education and 2 years of experience with children. A facility person's record shall include verification of childcare experience, education and training prior to service at the facility. Correction: Education records for staff #1 were sent for translation through one of the verified resources and will be kept on file. Inspection: Allocated Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Staff #1 was observed being supervised by another staff and in direct care with children on 5/1/26. Staff #1 had a disclosure statement on file dated 4/29/26, which was after they began working in direct care. Staff #1 did not have a completed NSOR on file and did not obtain the required Pa State Police clearance until 4/29/26, which is after they began working in direct care (see LIS Code Sheet for DOH). Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The CPSL was revised to include a requirement that all clearances be updated and on file at least every 60 months. As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL. Staff #1may not work in a childcare position with direct contact and routine interaction with children. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1may not work in a childcare position with direct contact and routine interaction with children. The correction date for this portion of the plan must be immediate. 2. The facility director and any other persons involved in the hiring of staff must register and attend an Existing Provider Orientation at a Regional Office. The provider must provide a correction date for when this portion of the plan will be completed. 3. In order to demonstrate compliance in this area, the director or legal entity representative will send completed staff files for all new hires for the next three months to the Northeast Regional Office for review. The staff files must include all clearance requests, completed clearances, (including out of state clearances and requests if necessary) signed and dated disclosure statement, health assessment and TB screening, two nonfamily references, proof of education and experience (officially translated if needed). The Northeast Regional Office will review the newly hired and completed staff files prior to hire within one week of receipt and provide a response back to the provider regarding suitability. The correction date for this portion of the plan must be three months from the acceptance of the plan by The Northeast Regional Office. Correction: 1. The operator will comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 was able to obtain the NSOR on 5/1/26 and was able to remain in childcare. 2. All required clearances has been placed on the staff #1 files, an existing provider orientation is scheduled for the Director on August 5th 2026. The Director will attend and take notes at the meeting and work to built a timeframe during the first week of hiring to make a plan and have new Staff to do and submit all the required documentations prior to hire or having any contact with children. Correction date 8/5/26 3. The director will send completed staff files for all new hires for the next three months to the Northeast Regional Office for review. The staff files must include all clearance requests, completed clearances, (including out of state clearances and requests if necessary) signed and dated disclosure statement, health assessment and TB screening, two nonfamily references, proof of education and experience (officially translated if needed). The Northeast Regional Office will review the newly hired and

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

CONTINUED NONCOMPLIANCE: On 1/22/26 the inspector observed a fire drill dated 7/22/25 and the next having been dated 9/30/25. The inspector received an acceptable plan of correction from the provider on 2/04/26. The facility's acceptable plan of correction indicated the correction would be implemented by 2/4/26. On 2/19/26 the inspector returned to the facility unannounced and observed the fire drill log and found that the last fire drill was documented as11/25/25. 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. TIERED LIS: 1. 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. The correction date for this part of the plan requires an immediate correction date. 2. The facility director will develop and implement a fire drill schedule that will ensure that all fire drills are conducted every 60 calendar days. The correction date for this should reflect a date that allows for the development and review of the schedule. Correction: 1. On February 19, 2026, a fire drill was conducted. Following a kind correction from the director's certification representative. The director was unaware that they didn't have to take the children and staff went outside the building to conduct a fire drill. Director didn't know that in case of inclement weather the fire drill could be conducted inside the building. Because the temperature was very cold the director decided to document on the fire drill that the drill was not conducted due to dangerous weather conditions. 2. Consequently, the certification representative kindly explained the correct way to conduct fire drills. In fact, the fire drill was carried out on the same day as the correction. The drill went smoothly the children were calm and it was a relief for the director and the staff because we didn't have to be outside for long, and we were already accustomed to doing it. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Volunteer #1did not have a current Pa Child Abuse as evidenced by the last Pa Child Abuse on file dated 8/25/20. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).As of 2/1/25 If staff or volunteers are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify them from employment based on CPSL. Volunteer #1 may not volunteer in a childcare position with direct contact and routine interaction with children. Correction: The director will comply with the CPSL Volunteer#1 will not return to the Center or have any contact with children until they have all necessary clearance and any other required document. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

Staff person #3 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid and CPR. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10 or (g)1-10, Pediatric First Aid and CPR Correction: On January 30th, 2026, staff #3 confirmed that they will not be able to continue working at Little Stars. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

Staff #3 completed the required pre-service training (see LIS Code Sheet), Health and Safety training over the 90 daytime frame allotted since hire. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10, health and safety training. Correction: On January 30th, 2026, staff #3 confirmed that they will not be able to continue working at Little Stars. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL (3270.32(a))

Volunteer #1 has not completed mandated reporter training within 90 days of their date of volunteering (see LIS code sheet). Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed volunteer #1 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 person(s) available to supervise volunteer #1, volunteer #1 may not work in a child- care position at the facility. Correction: Volunteer#1 will not return to the facility or have any direct contact with children until they have all necessary clearance and any other required documentation. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No peeling paint or plaster (3270.77(a))

Peeling paint was found on the half wall near the main entrance, accessible to children. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: On February 3rd, 2026, The director repainted the half wall near the main entrance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean, age appropriate (3270.106(a))

None of the cribs in the infant area were labeled for each individual child. Requirement: Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child. Correction: On February 2nd, 2026, the director appointed staff to label all the cribs with number code to ensure that the children are not sharing the cribs. Later the same day the director supervised their work and it was done correctly. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Surfaces cleaned (3270.135(b))

The diaper change mats in the toddler and infant areas both had rips exposing the foam underneath rending both change mats unable to be sanitized. Requirement: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering. Correction: On February 3rd, 2026 the director replaced/changed the diaper change mats. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB (3270.151(c)(2))

Staff # 3 did not have an initial tuberculosis screening by the Mantoux method since hire (see LIS Code Sheet for DOH). 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: On January 30th, 2026, staff #3 confirmed that they will not be able to continue working at Little Stars Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(6))

The annual emergency drill was previously conducted on 11/13/24 and not again until 12/16/25. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: On February 2nd, 2026, the director double checked the emergency drill log and noticed the gap between the months. Director is working along with a group supervisor to make sure that the annual drills are done on time. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The director did not conduct a fire drill every 60 calendar days. The inspector observed a fire drill dated for 7/22/25 and the next having been dated for 9/30/25. 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: The director double checked the monthly fire drill log and noticed the gap. The director appointed the group supervisor to assist the director in keeping track of the log to make sure that the fire drill is conducted every 60 calendar days (within the 60 days). 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))

During the unannounced inspection on 1/22/26 the inspector observed the fire drill/detection log and found that the facility did not conduct a manual test of the fire alarms every 30 calendar days. The inspector observed a manual test dated on the fire drill/detection log for 4/03/25 and the next having been dated for 5/5/25, and 7/1/25 and the next having been dated for 8/12/26, and 10/01/25 and the next having been dated for 11/13/25. 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: The director double checked the fire detection log and not all the manual fire detection testing met the 30 day mark. Some months have days of gaps. On February 3rd, 2026, the director conducted the manual fire detection testing within 30 days. Previous manual testing was done on January 6th, 2026. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Consent for administration of minor first-aid required prior to admission (3270.182(5))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the child files and found that child files #1 and #2 were missing the required signed parental consent for administration of minor first-aid procedures by facility staff Requirement: A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission. Correction: Parental consent was signed by parent for child #1 and #2 was placed back to child files 2/5/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Bottles labeled (3270.166(4))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the infant bottles in the infant room to not be labeled as is required. Requirement: Disposable nursers and bottles shall be labeled with the child's name. Correction: Baby bottle label stickers was ordered & will be received on 2/1/2025m baby bottle stickers was placed on baby's bottle on 2/6/25. 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))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the file for staff #7 and #8 to be working in direct care and without health assessments and TB screenings as are required (see LIS code sheet for DOH). 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: On 1/31/2025 the director sent staff #8 to do TB screening as required and result was negative. Staff #7 hand in their physical exam and the TB screening was negative and they were clear to work. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Disposable diapers (3270.135(a)(3))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the garbage can in the infant room to not be handsfree as is required. Requirement: If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can. Correction: 2 pedal hands-free garbage can was ordered and will be received on 02/05/2025. After received the garbage can they will be placed in the infant room and young toddler room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the child files and found that child files #1, #2, #4, and #5 were missing the required address and telephone number of the individual designated by the parent to whom the child may be released. Requirement: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released. Correction: Director working with parents gathering information that is not completed and signing the emergency contact information for children's files on 2/3/25, 2/5/25 and 2/6/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written consent (3270.124(b)(4))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the child files and found that child file #2 was missing the required written consent signed by a parent for emergency medical care. Requirement: Emergency contact information must include the written consent signed by a parent for emergency medical care. Correction: Emergency medical care was signed by parent on 2/5/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the child files and found that child files #1, #2, #3, #4, and #5 were all missing the required work addresses and telephone numbers of the enrolling parent. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: Director is currently working with parents gathering information and filling work's address and phone numbers information on every child's file that might be need it. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the file for staff #2, #3, #4, #5, and #7 and found that all five staff did not have a minimum of one evaluation every 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: Staff #2, #3, #4, #5, and #7 last evaluation was 12/30/24 and were updated on 1/31/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Durning the unannounced renewal inspection on 1/23/25 the inspector observed the file for staff #1, #2, #4, #5, and #6 and found that all five staff did not have annual fire safety training conducted by a fire protection professional as is required. 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: On January 31st, 2025, the director double checked and made copies of every staff fire safety training on PD Registry and send the copies to the DHS office t show current training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).