THE CHILDRENS GARDEN OF ST JOHNS LUTHERAN CHURC

Promote development (3270.111(c))

It was observed that in the older toddler classroom that the physical environment and daily activities provided by staff persons #1 and #2 do not promote the development of skills, social competence and self-esteem. Requirement: Tiered LIS: 1.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. This portion of the plan shall have an immediate correction date. 2.The legal entity must arrange for the older toddler classroom staff to receive a minimum of two hours of training and 2 hours of TA regarding classroom environment and programming. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date of when the training and TA will be completed. Correction: 1. Daily activities that promote the development of skills, social competence and self-esteem have been implemented in the OT classroom with management monitoring them. 2. The OT classroom staff will receive 2 hours of training and 2 hours of training and 2 hours of TA regarding classroom environment and programming. 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))

It was observed that two incidents occurred with child #1 where incident reports were either not written or was not given to the parent. 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: - Incident reports will be written and given to parents at pick-up - Incident reports will be filed in the office, in the child's file, and in the classroom. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

in the older toddler classroom child #1 was able to push over a bookshelf and bite peers while being supervised by staff persons #1 and #2. 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. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for the older toddler classroom staff to receive a minimum of two hours of 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 of when the training and TA will be completed. Correction: 1. The children must be supervised at all times. (4/10/26) 2 The teachers in OT will receive 2 hours training on supervision. The classroom will also receive TA assistance twice. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Promote development (3270.111(c))

Staff #1 stated they carried Child #1 to the office while the child flailed, kicked, and would not walk. Staff #1 held the child on their lap and restrained the child's movement for a minimum of 10 minutes. During this timeframe, Staff #1 stated the child was yelling and kicking. Requirement: 1. 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. This portion of the plan should have an immediate correction date. 2. The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding appropriate daily activities to use with children. Following the training, the legal entity must arrange for at least two technical assistance (TA) sessions in any classroom that requests TA in using appropriate daily activities. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date of when this training will be completed. Correction: 1. Daily activities will promote the development of skills, social competence and self-esteem. (2/9/26) 2. The employees will receive 2 hours of training along with 2 hours of TA. In addition, staff will do a second training on BKC. Management will step into classrooms for a behavior and help teachers, using TA, advise and implement measures for the child to remain in the classroom, avoiding office visits. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Promote development (3270.111(c))

Self- report investigation revealed that during naptime in the young toddler classroom, staff #1 was observed patting child #1 in an aggressive manner and laying their arm across them to keep child #1 on their cot. Child #1 was also observed to have their head covered by a blanket. Requirement: TIRED LIS: 1. A facility person must use 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. This portion of the plan shall have an immediate correction date. 2. The legal entity shall arrange for all facility staff to receive a minimum of two hours of in-person training regarding appropriate naptime practices. The training must include information about safe sleep and appropriate strategies for assisting children who resist nap time. Following the training, the legal entity must arrange for at least two technical assistance (TA) sessions in the young toddler classrooms and any other staff that requests TA in their classrooms. The legal entity must receive DHS approval of the training content and TA prior to scheduling the training. The operator shall provide a date of 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 is promoting daily appropriate activities during naptime (for example a daily naptime staff observation checklist completed by the director). 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. The correction date for this portion of the plan shall be at minimum 3 months from the date the Regional Office approves the checklist. Correction: 1. Staff members will use daily activities that promote development of skills, social competence and self-esteem. (1/30/26) 2. All staff will receive 2-hours of in-person training regarding appropriate naptime policies; staff will also plan for two TA sessions in young toddler class. (3/16/26) 3. Director shall submit documentation of a DHS approved naptime observation checklist. This shall be submitted weekly to DHS for a period of 3 months. (5/8/26) Inspection: Self-Reported Non Compliance. 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))

Documentation shows that the fire detection system was not tested every 30 days. 12/3/25 and 1/7/26 (35 days) Requirement: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met. Correction: We Will mark on our calendars the day it needs to be done. Inspection: 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 persons #1, #2, and #3 were observed working with children and did not have a current health assessment on file nor did they have a TB test at initial employment on file. 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 persons #1, #2, and #3 will get health assessments immediately. Staff #1 app't on 1/22, staff #2, current as of 1/10/26, staff #3 app't on 1/20. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff assigned to specific children (3270.113(a)(1))

Child #1 in PK-1 was left in the bathroom for approximately 2-5 minutes by staff persons #1 and #2 when the class went back to the classroom. Child #1 was discovered by another teacher when their class was in the bathroom. Child #1 was never alone in the bathroom. Requirement: 1. 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 should have an immediate correction date. 2. The legal entity must arrange for all facility staff to receive a minimum of two hours of 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 of when this training will be completed. Correction: Each staff person will be assigned the responsibility for specific children in their primary care group. (1/8/26) All staff will have a training on supervision on 2/3/26 at 5:30 by ELRC. (2/27/26) Inspection: Complaints- Legal Location. 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))

Child #1 had scratch marks and red marks on their cheek, and an incident report was not written nor given to the parents the day of the incident. 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: Incident reports will be written by staff when accidents, injuries and illnesses occur involving a child in care at the facility. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff assigned to specific children (3270.113(a)(1))

In the PK-2 classroom staff member #1 was unable to name the children in their primary care group. 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. Correction: All staff person shall be assigned the responsibility for supervision of specific children. That staff persons will know the names and whereabouts of the children in their assigned group. That staff persons will be physically present with the children in their group. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

An altercation took place between child #1 and child #2 in the PK-2 classroom. Staff persons #1 and #2 were unable to give an amount of time that the altercation took place or the amount of time it took for them to notice the altercation. 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. Correction: Staff members will maintain supervision in the classroom. Staff will be aware of child interactions in the classroom. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff assigned to specific children (3270.113(a)(1))

It was observed that in the OT classroom staff persons 1 and 2 named 12 of 17 children. It was observed that in the PK-2 classroom, staff person #3 was unable to name the children in care during nap time. It was observed that in the PS-1 classroom there were 14 children and staff persons 4 and 5 named 13 children. It was observed that in the PK-1 classroom, staff person #6 was working alone during nap time, but only named the children in their care group not all the children in the classroom. 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. Correction: Staff that are new to a classroom will be given tools to help them identify their care groups. Cards with photos and names will be used by the staff. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Similar Age Level (3270.51)

On 11/18/25, the kindergarten classroom with 22 five-year-olds and the PK-2 classroom with 16 four and five-year-olds were out of ratio for 25 to 30 minutes as one staff person was left supervising the children in each of the aforementioned classrooms. Requirement: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. Correction: Staff was reinstructed on the importance of keeping ratios and what their correct ratios are. We also confirmed with staff the correct procedure to call for help when out of ratio. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No smoking areas (3270.68(a))

Facility Self- Reported the following incident occurred on 8/15/25: Facility person #1, employed by an outside agency, was observed to have a vape pen in hand and was actively smoking in the childcare facility. Requirement: Cigarettes, pipes or cigars may not be smoked in a childcare space, a play space or a food preparation area when children are in care or when food is being prepared. Correction: 1. Staff member informed lead teacher. Lead teacher went to inform Director. 2. Director removed support representative from the classroom. Inquired about observation. Support person admitted having the "pen." Individual left for the day. 3. Director contacted state DHS, parent, and supervisor of agency. Documentation was sent to agency. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Promote development (3270.111(c))

Staff persons #1 and #2 were reported to have used loud tones and impatient language with children. 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. Correction: Staff members will take training focusing on positive interaction with young children. Staff change. Staff #2 moved to school aged classroom. Observations of child- teacher interactions. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(5))

On 1/24/25, it was observed that the facility emergency plan did not include a plan for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. CORRECTED ON SITE. Requirement: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Correction: -Director added addendum to our current operational emergency plan. -Added new plan to email. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Exam communicable disease (3270.151(c)(3))

On 1/24/25, it was observed that the health assessment for staff person 1 did not include the results of screening for communicable diseases. Requirement: An adult health assessment must include an examination for communicable diseases and the results of that examination. Correction: -Documented on health assessment which included the results of communicable diseases. -Provided attachment Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Services proceeded (3270.123(a)(3))

On 1/24/25, it was observed that the agreement forms for children 1, 2, 3, 4, 5, 6, 7, 8, and 9 did not include serveices that would be provided to the children. Requirement: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Correction: -Made correction to agreement specific to the services rendered. -Sent attachment of her agreement. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.66(b))

On 1/24/25, it was observed that magic erasers were stored without their original container and were not labeled in the Preschool 2 and Tot classrooms. CORRECTED ON SITE. Requirement: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces. Correction: -Provide staff with education about keeping magic eraser in container marked toxic. -Magic Erasers were labeled. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

On 1/24/25, it was observed that White Out was accessible to children in the PreK 2 and Preschool 2 classrooms. CORRECETED 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: -Added to our health and safety checks about toxic materials being accessible to children. Provide staff with examples of items which may be overlooked. -White Out was removed and made inaccessible to children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).