CHRISTIAN CHILD CARES LLC

Health and Safety Training - Pediatric First Aid and CPR (3270.31(f)(10))

During renewal inspection on 12/15/25, staff files were reviewed. Staff #5 did not have documentation of completing Pediatric CPR on file. (See code sheet for date of hire). Requirement: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Correction: Upon notification of the violation, the facility reviewed Staff #5's personnel file and confirmed that documentation of Pediatric CPR/First Aid training was not present. The staff #5 has been scheduled to complete Pediatric CPR and First Aid training. Upon completion, documentation will be placed in the staff member's personnel file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Transcript, diploma and letters (3270.192(2)(iv))

During renewal inspection on 12/15/25, staff files were reviewed. Staff #2 did not have documentation of education on file. Staff #3 & #4 did not have documentation of childcare experience on file. Staff #5 did not have documentation of education or childcare experience on file. Requirement: A facility person's record shall include 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: Upon notification of the violation, the facility immediately reviewed the personnel files for Staff #2, #3, #4, and #5. A copy of Staff #2's education diploma was obtained on the same day as the inspection and placed in the staff member's personnel file. For Staff #3 and #4, updated documentation verifying childcare experience was completed and placed in their personnel files. For Staff #5, documentation of education and childcare experience, including a copy of the diploma and completed reference verification, was obtained and has been added to the staff member's file. The facility is conducting a review of all staff personnel files to ensure acceptable verification of education, training, or experience is present and properly documented. Any missing documentation will be corrected immediately. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mantoux TB/Health assessment, TB test (3270.151(c)(2)/3270.192(3))

During renewal inspection on 12/15/25, staff files were reviewed. Staff #6 did not have a TB test done prior to working with children. Staff #8 last health assessment is dated for 3/10/23. An updated assessment was not obtained until 12/9/25. 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. 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 notification of the violation, the facility immediately reviewed the health assessment documentation for Staff #6 and Staff #8. Staff #6's was asked to get her health assessment documentation updated to show a Negative TB screening or medical exemption due to her pregnancy to reflect the required health assessment documentation and tuberculosis screening. Staff #8's updated health assessment was obtained upon return from medical leave and placed in the staff member's personnel file. All staff files were reviewed to ensure required initial and updated health assessments, including tuberculosis screening documentation, are current and properly maintained. Any missing or outdated documentation was corrected immediately to ensure compliance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No insects or rodents (3270.67(c))

During renewal inspection on 12/15/25, rep conducted a physical site overview. When getting the To-Go Bag to check the first aid kit in the school age room, rep observed two roaches behind the bag. Requirement: Evidence of infestation of insects or rodents in the facility is not permitted. Correction: Upon discovery of insect activity, the facility immediately contacted a licensed professional pest control company, Pest Rangers, to address the issue. The affected areas were treated, and corrective measures were implemented to eliminate the infestation. Documentation of the service receipt and a signed contract for ongoing pest control services were obtained and made available to the inspector. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During renewal inspection on 12/15/25, staff files were reviewed. Staff #1s latest NSOR clearance is dated for 10/14/2020. There was not an updated clearance on file and staff #1 was observed working with children. Staff #5 did not have mandated reporter training on file and was observed working with children. (See code sheet for dates of hire). Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). This portion shall have an immediate correction date. Staff #1 cannot work in childcare until all clearances are updated and valid. 2. The legal entity and director must attend existing provider orientation at any regional office location. The operator shall provide a date for when this training will be completed. Correction: Upon notification of the violation, Staff #1 was immediately removed from direct contact with children until all required clearances were updated and verified. Staff #1 completed the required NSOR clearance immediately, and the updated clearance was placed in the staff member's personnel file upon receipt. The facility reviewed Staff #5's personnel file and confirmed that a copy of documentation of Mandated Reporter training was not on file although Staff #5 had already completed this training. A copy of the completed Mandated Reporter certificate was obtained immediately and placed in the staff member's personnel file. In addition, the facility conducted a review of all staff files to ensure required clearances and Mandated Reporter training documentation are current and properly maintained. Any missing documentation was corrected immediately. The legal entity and Director will attend the required provider orientation as directed by DHS, and a completion date will be provided upon scheduling. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During renewal inspection on 12/15/25, staff files were reviewed. Staff #1 previous fire safety training was dated for 8/18/24. An updated training was not completed until 11/29/25. This date indicates that fire safety training was not done month to month, annually. 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: The staff member identified completed updated fire safety training on 11/29/25. Upon discovery that the annual training interval had not been met within the required timeframe, the facility reviewed all staff training records to confirm current fire safety training status. Any discrepancies were immediately addressed to ensure all required annual fire safety training was completed and documented. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During renewal inspection on 12/15/25, staff files were reviewed. Staff #4 did not have any documentation of completing health and safety training in the file. (See code sheet for dates of hire). 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. Correction: Upon notification of the violation, the facility reviewed Staff #4's personnel file and confirmed that documentation for the required Health and Safety training was not on file. The staff member was immediately notified and was asked to provide a copy of the certificate of completion for the required Health and Safety training. Ms. Janet's email was also searched after the inspection and a copy of the said document was found and has been placed in the staff member's personnel file. Additionally, the facility has conducted a review of all staff files to ensure required Health and Safety training documentation is present. Any identified gaps will be addressed to ensure compliance going forward. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Updated every 6 months/Emergency info/agreement updated 6 mos (3270.124(f)/3270.181(c))

During complaint inspection on 8/26/25, it was observed that child #1's emergency contact sheet and financial agreement form was last updated on 12/21/24. This date indicates that both forms were not updated within the 6-month requirement. 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. A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information. Correction: Child #1's emergency contact and financial agreement forms were immediately reviewed and updated upon discovery. All other children's files were also reviewed, and parents were contacted to update any expired or missing forms. Notices were sent to families reminding them of the 6-month update requirement for emergency contact and financial forms to ensure all records remain current. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

During complaint investigation on 8/26/25, it was discovered that several toys on the outside playground were broken, chipped and not in good repair. The toys were a basketball hoop and a fountain-like structured toy. Requirement: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts. Correction: The damaged basketball hoop and fountain-like toy were immediately removed and discarded upon discovery. Staff conducted a full inspection of all indoor and outdoor toys and equipment the same day, removing any additional items that were broken, chipped, or unsafe. The outdoor play area was checked to ensure all remaining equipment is clean, in good repair, and safe for use by children. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Heat Source/Building Surfaces (3270.71/3270.76)

During complaint investigation on 8.26.25, it was observed in the diamond section that the toaster oven was accessible to the children. It was also observed that there was a loose extension cord on the right side of the fridge and accessible to the children. Requirement: Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact. Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Correction: The toaster oven, microwave, and all extension cords were immediately removed from the Diamond classroom area and relocated to a secure staff-only location that isn't accessible to children without supervision. The loose extension cord beside the refrigerator was secured and repositioned to eliminate access and potential hazards. Staff were reminded that all electrical items and heat sources must remain out of children's reach at all times. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file (3270.182(7))

During complaint investigation on 8/26/25, it was discovered that the parent of child #1 did not receive an incident report regarding the child eloping from the facility's playground. Requirement: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file. Correction: Although an incident report was not completed at the time of the event, the parent of Child #1 was immediately contacted by phone and informed of the incident, followed by a text message confirmation. Following the complaint investigation, the facility completed an incident report for the occurrence and placed copies in the child's file and the accident log. All staff were reminded that an incident report must be completed for any accident, injury, illness, or unusual incident---including elopement---and that a copy must be given to the parent on the same day. The facility reviewed the required procedure and proper documentation steps with all staff. Inspection: Complaints- Legal Location. 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))

During complaint investigation on 8/26/25, it was discovered that Child #1 eloped from the outside playground on 8/16/25. This was confirmed by interviews with staff. Also, during investigation on 8/26/25, cert rep completed supervision and ratio. Staff within the school age diamond room were unable to identity the children in their assigned groups. Requirement: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person 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/her assigned group. The staff person shall be physically present with the children in their group on the facility premises and on facility excursions off the facility premises. Outdoor play space used by the facility is considered part of the facility premises. TIERED LIS: 1. Children must be supervised at all times. This portion of this 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 supervision training. The legal entity must receive DHS approval of the training content prior to scheduling the training. The training cannot be conducted when children are in care. The operator shall provide a date for when this training will be completed. 3. The legal entity must create a written supervision policy to include name to face recognition as well as a written policy for handling children who elope. The legal entity will need to have all staff review the new policy, sign a document stating that it has been reviewed and it shall be kept in each staff file. This policy must be approved by DHS before implementation. The correction date for this portion of the plan shall be at minimum two months from the date the Regional Office approves the policy. Correction: Upon discovery of the incident, Child #1 was immediately located, safely returned to supervision, and the child's parent was promptly notified and asked to pick up the child. All staff were immediately reminded that children must be supervised at all times, including during outdoor play. Staff involved received immediate coaching and were reassigned to ensure proper coverage. A headcount and name-to-face recognition procedure was implemented immediately for all transitions and outdoor play. Children will be supervised at all times. The correction date for this is 10/24/25. The facility will schedule a minimum of two hours of in-person supervision training for all staff once the training content is approved by DHS. The training will focus on active supervision, name-to-face procedures, group management, and elopement prevention. The center's existing Supervision Policy was reviewed and updated to strengthen procedures related to name-to-face checks and elopement response. Staff will review and sign the updated policy, and copies of the signed acknowledgements will be kept in their personnel files. This policy will be sent to DHS for review. Inspection: Complaints- Legal Location. 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 renewal inspection, it was observed that the following dates indicate that the facility did not test the fire alarm system within 30-day requirement: 1/24/24, 2/28/24, 4/26/24, 5/31/24, 6/20/24, 7/25/24, 8/22/24, 9/25/24, 10/28/24. 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: 1. Immediate Action: ¿ Conduct Immediate Fire Drill: We conducted an immediate fire drill to test the functionality of the fire alarm system. ¿ Document Test: Document the date and time of the fire drill and the results of the test in the state's provided template. 2. Schedule Regular Testing: ¿ Establish Testing Schedule: Implement a regular schedule for monthly fire alarm system testing. For example, we will test the alarm within 25 days from previous test. So if a test was done on January 10th, the next test will be on February 5th. ¿ Assign Responsibility: Our staff lead will be responsible for conducting monthly fire alarm tests and maintaining testing records while providing information to owner/director. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

On file at facility (3270.18(a))

During renewal inspection, it was observed that the facility did not have active liability insurance. Requirement: The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility. Correction: 1. Immediate Action: ¿ Obtain Insurance: Immediately contacted our vehicle insurance broker/agent to get us a liability insurance policy. ¿ Confirm Coverage: Verified that the policy meets all the requirements outlined by the licensing regulations (coverage amounts, types of coverage). 2. Document Correction: ¿ Obtain Certificate of Insurance: Secure a current Certificate of Insurance from the insurance company. ¿ Place on File: Place the original Certificate of Insurance in a designated and easily accessible location within the facility. 3. Notification: Notify Licensing Agency: Within 15 days of the corrective action, I will notify the State agency in writing that the insurance policy has been reinstated and a copy of the Certificate of Insurance has been placed on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency Numbers Posted/Promote development (3270.74/3270.111(c))

During renewal inspection, it was observed in the Gold Room that there was not a daily activities schedule posted and that emergency telephone numbers were not posted. Requirement: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility. 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. Correction: 1. Immediate Action: ¿ Post Emergency Contacts: (Already completed) Verify that emergency contact numbers (hospital, police, fire department, ambulance, poison control) are clearly and prominently posted in the Gold Room and throughout the facility. 2. Develop and Post Daily Activity Schedules: ¿ Create Schedules: Develop and implement a system for creating daily activity schedules for each classroom, including the Gold Room. ¿ Post Schedules: Ensure that a daily activity schedule is clearly posted in each classroom, including the Gold Room, for easy viewing by staff, parents and all visitors. ¿ Schedule Content: Ensure that daily schedules include a variety of developmentally appropriate activities that promote the cognitive, social, emotional, and physical growth of children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).