END TIME REMINDER MINISTRIES ACADEMY

Indoor space- small muscle (3270.61(a))

During a renewal inspection conducted on 12/01/25, the Certification Representative conducted a walkthrough of the facility and observed the indoor gym was converted to an infant room. Requirement: A facility shall provide indoor child care space for individual and group small muscle activity. Correction: We have identified an alternative room within the facility that will now serve as the dedicated indoor child care space for individual and group small muscle activity. The gym space will no longer be used as an infant room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e))

During a renewal inspection conducted on 12/01/25, the Certification Representative review Staff's #1 and Staff's #2 content of records. Staff's 1 and Staff's 2 content of records did not include 12 hours of training. Requirement: A staff person shall obtain an annual minimum of 12 clock hours of child care training. Correction: Both staff members have now been enrolled in and/or completed the required training hours. Updated certificates and training documentation have been obtained and placed in each staff member's personnel file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed Staff's #3 content of records. Staff's #3 content of records included the wrong Pediatric First Aid training. Requirement: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Correction: The staff member (#3) who completed the incorrect Pediatric First Aid training has been immediately scheduled to retake and complete a Department of Human Services (DHS)-approved Pediatric First Aid and Pediatric CPR course. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exceeding Capacity (3270.61(h))

During a renewal inspection conducted on 12/01/25, the Certification Representative conducted a walkthrough of the facility and observed the indoor gym exceeded capacity with the infants placed in the room. Requirement: The capacity established for an indoor space may not be exceeded except in situations described in § 3270.61(h)(1-3) Correction: Upon notification of the capacity violation, the infants were immediately removed from the indoor gym and returned to their assigned classroom to maintain compliance. Signage indicating room capacity limits have now been posted in all shared spaces, including the gym. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed staff's #3 content of records. Staff's #3 content of records did not include two letters of reference. 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 reference letters attesting to Staff #3's suitability to work with children were obtained and added to the staff member's personnel file by the correction date. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exp, educ., training prior to facility (3270.192(2)(ii))

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed staff's #4 content of records. Staff's #4 content of records did not include a verification of education. Requirement: A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: The required education documentation has since been obtained and placed in Staff #4's personnel record. The personnel file is now complete and compliant with DHS requirements 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))

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed Staff's #4 content of records. Staff's #4 content of records did not include a physical health assessment. Requirement: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. 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: The facility has immediately scheduled Staff #4 for a comprehensive physical health assessment, including TB screening, through a certified medical provider. The completed documentation will be added to the employee's personnel file and reviewed for accuracy and compliance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Crib, playpen: 2 3/8 inch slats/2 feet apart (3270.106(d)/3270.106(f))

During a renewal inspection conducted on 12/01/25, the Certification Representative conducted a walkthrough of the facility and observed the playpens are not 24 inches apart. Requirement: Crib and playpen slats may be no more than 2 3/8 inches apart. At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use. Correction: Effective immediately, the facility rearranged the infant room to ensure that all playpens and cribs are placed at least 24 inches apart on three sides while in use, as required by PA Code 3270.106(d)/(f). The staff was re-trained on crib and playpen spacing regulations. A floor plan was adjusted to accommodate the spacing requirement without compromising the safety or supervision of children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No bed linens alone/Prohibit items in crib (3270.106(b)/3270.106(j))

During a renewal inspection conducted on 12/01/25, the Certification Representative observed an infant sleeping with a blanket wrapped around the entire body. Requirement: Bed linens may not be used alone as age-appropriate rest equipment. Toys, bumper pads, or pillows may not be present in a crib while an infant is sleeping in the crib. Correction: The provider removed all blankets and linens from the playpen. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean, good repair, proper size (3270.104(a))

During a renewal inspection conducted on 12/01/25, the Certification Representative conducted a walkthrough of the facility and verified he shelves in the Pre-School room and found the shelves big and unstable. Requirement: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs. Correction: The provider removed all the shelving units that were not stable. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed staff's #3, and Staff's #4 content of records. Staff's #3 content of records did not include an FBI results clearance. Staff's #4 content records did not include the NSOR results clearance. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. 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 a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #--- may not work in a child care position at the facility. Correction: Both staff members were immediately removed from contact with children pending receipt of the required clearances. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed staff's #1, Staff's #2, and Staff's 3 content of records. Staff's content of records did not include an annual fire safety training. 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: Training will include protocols for drills, fire extinguisher use, and smoke detector maintenance. Certificates of completion will be placed in staff files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed Staff's #1, Staff's #2, Staff's #3 and Staff's #4 content of records. Staff's content of records did not include an annual and new hire emergency plan review. 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: The Director has since conducted an emergency plan review with all identified staff, covering evacuation, shelter-in-place, lockdown, and relocation procedures. Each staff member has signed and dated an acknowledgment form, which has been placed in their personnel files. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During a renewal inspection conducted on 12/01/25, the Certification Representative reviewed staff's #3 content of records. Staff's #2 content of records did not include Health and Safety 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. Correction: The required Health and Safety training has now been completed, and documentation has been obtained and placed in Staff #2's personnel file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

During a renewal inspection conducted on 11/19/24, the Certification Representative reviewed Stafft's #2 content of records, and the content of records of Staff's #2 did not include two letters of references. 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: The owner immediately requested staff's #2 for the two letters of references. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Refrigerator (3270.107)

During a renewal inspection conducted on 11/19/24, the Certification Representative inspected the refrigerator for a temperature and observed the refrigerator did not have a thermometer placed for a reading of the temperature. Requirement: A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator. Correction: The owner will order or pick up a thermometer as soon as possible. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).