SHADY LANE SCHOOL

Supervised at all times (3270.113(a))

Self-reported noncompliance incident occurred on 4.7.26, at approximately 10:30 AM. Staff #1 and Staff #2 were supervising a group of ten (10) toddlers in the gym. Child #2 was assigned to Staff #2's care and was left unsupervised in the gym when the group transitioned back to the Yellow Room. Staff #3 located Child #2 alone and unsupervised in the gym and returned the child to the classroom. Requirement: TIERED LIS Tier 1 - 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. The operator must provide an immediate correction date for this portion of the plan. Tier 2 - The legal entity shall ensure the director and a representative of the executive leadership team register for and attend the next available Existing Provider Training conducted by the Western Region Office. Registration for the training shall occur within (2) weeks of the plan of corrections being accepted. Training hours may apply toward the annual clock-hour training requirements. Documentation of training completion shall be submitted to the Western Regional Office within five (5) business days of completion. The operator shall provide a date for when this portion of the plan will be completed. Tier 3 - The legal entity shall ensure the director, and a representative of the executive leadership team, participate in supervision focused technical assistance with the Early Learning Resource Center (ELRC) Region 5 representative and the Program Quality Assessment team to complete a comprehensive program assessment to obtain authentic data as a baseline for feedback conversations to address any systemic issues that may arise from observations. An observation window shall be scheduled within two (2) weeks of the plan of corrections being accepted. Following completion of the assessment, the legal entity shall work with the ELRC Region 5 representative and Program Quality Assessment team to develop and implement procedures to address any identified systemic issues related to child accountability and supervision during transitions. The procedures shall include assigning children to a specific staff person, conducting a child count prior to each transition, lining children up before leaving a childcare space, gym, outdoor play space, or restroom, and conducting a visual sweep of the childcare space prior to transition. These procedures shall be followed during all transitions throughout the facility. All facility persons shall receive training on the procedures and sign an acknowledgement confirming receipt of the training. The legal entity shall implement any additional recommendations identified through the assessment process and submit a copy of the assessment findings, staff training acknowledgements, and documentation of implementation to the Western Regional Office within five (5) business days of completion. The operator shall provide a date for when this portion of the plan will be completed. Tier 4 - The director shall complete a minimum of three (3) weeks of observation before holding monthly meetings with staff. A minimum of three (3) consecutive monthly meetings shall be held. The director shall prepare an agenda for each monthly meeting that includes review of monitoring observations and relevant Department-issued inspection summaries. Staff in attendance shall sign an acknowledgement for each meeting. The director shall document that meeting content was communicated to staff who were not in attendance. The agenda, meeting documentation, and staff acknowledgements shall be submitted to the Western Regional Office within five (5) business days after each monthly meeting for a minimum of three (3) months. The operator shall provide a date for when this portion of the plan will be completed. Tier 5 - The legal entity shall ensure the director, and a representative of the executive leadership team sh

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

Self-reported noncompliance incident occurred on 4.7.26, at approximately 10:30 AM. Staff #1 and Staff #2 were supervising a group of ten (10) toddlers in the gym. Child #2 was assigned to Staff #2's care and was left unsupervised in the gym when the group transitioned back to the Toddler Room. Staff #3 located Child #2 alone and unsupervised in the gym and returned the child to 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. These citations do not include directed tiers. The provider correction date must be changed from 9/2/2026 to an immediate correction date. Correction: The deficiency was corrected immediately. All staff were reminded that each child must be assigned to a specific staff member who is responsible for knowing the child's name and whereabouts at all times (care groups). Staff are required to remain physically present with their assigned children throughout the day, including during classroom activities, outdoor play, restroom breaks, and all transitions on and off the facility premises. Administration immediately reviewed child supervision policies with all staff, including active supervision expectations, child accountability procedures, and transition protocols. Staff were instructed to conduct and document name-to-face child counts before, during, and after every transition and to complete a visual sweep of each area before leaving. Administration will continue to conduct routine supervision observations and monitor compliance. Any staff not following supervision procedures will receive immediate coaching and retraining. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No physical punishment (3270.113(b))

A complaint of non-compliance was investigated. On 4.10.26, at approximately 11:00 AM, in the Pink Room, Staff #1 was physically aggressive with Child #1 when grabbing the child by the biceps/upper arms and holding the child in the air. Requirement: A facility person may not use any form of physical punishment, including spanking a child. These citations do not include directed tiers. The provider correction date must be changed from 9/2/2026 to an immediate correction date. Correction: The deficiency was corrected immediately. The ED and another member of leadership met with the staff member in question to review the facility's discipline policy and the Department's prohibition against all forms of physical punishment, including spanking or any other physical disciplinary practice (holding a child by their arms). Staff were reminded that positive guidance and developmentally appropriate behavior management techniques are the only acceptable methods of discipline. Expectations regarding appropriate child guidance, professional conduct were reviewed. Administration will monitor staff interactions with children through ongoing classroom observations and supervision. Any concerns regarding discipline practices will be addressed immediately through coaching, retraining, and, when appropriate, personnel action in accordance with facility policies. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No harsh language (3270.113(d))

A complaint of non-compliance was investigated. On 4.10.26, in the Pink Room, Staff #1 lifted Child #1 up to eye level and loudly screamed, "Stop," in Child #1's face while showing frustration. Requirement: A facility person may not use harsh, demeaning or abusive language in the presence of children. These citations do not include directed tiers. The provider correction date must be changed from 9/2/2026 to an immediate correction date. Correction: The deficiency was corrected immediately. The ED and another member of leadership met with the staff member in question to review the facility's discipline policy and the Department's prohibition against all forms of physical punishment, including spanking or any other physical disciplinary practice (holding a child by their arms). Staff were reminded that positive guidance and developmentally appropriate behavior management techniques are the only acceptable methods of discipline. Expectations regarding appropriate child guidance, professional conduct were reviewed. Administration will monitor staff interactions with children through ongoing classroom observations and supervision. Any concerns regarding discipline practices will be addressed immediately through coaching, retraining, and, when appropriate, personnel action in accordance with facility policies. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

General Health and Safety (3270.21)

In the green room on a shelf by the door, 2 pair of adult scissors, push-pins, and a jaw-style staple remover were accessible to children. In the blue room in an unlocked drawer at the sink there was a potato peeler. Also, in the blue room a stapler was on a low shelf accessible to children. Requirement: Conditions at the facility may not pose a threat to the health or safety of the children. Correction: On 12/19/2025, the cited items were immediately removed from child-accessible areas. In the green room, the adult scissors, push-pins, and jaw-style staple remover were removed from the shelf by the door and placed in a locked cabinet inaccessible to children. In the blue room, the potato peeler was removed from the unlocked drawer at the sink and secured in a locked storage area. The stapler located on a low shelf in the blue room was removed and placed in a locked cabinet. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

The most recent Emergency Plan training was conducted on 8/27/25 more than 12 months from the previous Emergency Plan training conducted on 7/31/24. The files for Staff #1 and #9 contained documentation of Emergency Plan Training completed on 8/27/25. The files for Staff #1 and #9 lacked documentation of Emergency Plan Training for the previous year. The files for Staff #3, #4, #6, #8, and #10 contained documentation of Emergency Plan Training completed on 8/27/25 which was more than 12 months from the previous Emergency Plan training conducted on 7/31/24. The file for Staff #7 contained documentation of Emergency Plan Training completed on 8/27/25 which was more than 12 months from the previous Emergency Plan training conducted on 1/10/24. 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: A full audit of all personnel files was conducted to identify missing or outdated training records. Any missing documentation was addressed, and staff files were organized to ensure training records are clearly maintained and easily accessible for review. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Letter to parents (3270.27(e))

The facility lacked a parent letter explaining the emergency plan procedures. Requirement: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan. Correction: On 1/6/2026, a parent letter outlining the facility's Emergency Plan procedures was developed. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training (3270.31(e)(4)(i))

The file for Staff #3 contained pediatric first aid and CPR training completed on 6/3/25 which was obtained after the previous first aid and CPR training expired in June 2024. Requirement: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Correction: Staff #3 completed pediatric First Aid and CPR training on 6/3/25, and current documentation has been placed in the staff file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file for Staff #8 contained fire safety training completed on 11/4/25 which was more than 12 months from the previous fire safety training dated 5/24/24. 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: Staff #8 completed fire safety training on 11/4/25, and documentation of the current training has been placed in the staff file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

Staff #5 has completed first aid and CPR training, however the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training has been completed, staff #5 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 staff #5, staff #5 may not work in a child-care position at the facility. Correction: Staff #5 was registered for and completed a PQAS approved first aid/CPR training on 12/19/2025, immediately following notification of the infraction. Documentation of the approved training was placed in the staff file upon completion. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The file for Staff #3 (See LIS Code Sheet) contained an NSOR certificate dated 5/22/25 which was obtained more than 60 months from the previous NSOR certificate dated 4/30/20. The file for Staff #8 (See LIS Code Sheet) contained a PA State Police clearance dated 10/6/25 obtained more than 60 months from the previous PA State Police clearance dated 1/21/20; PA Child Abuse clearance dated 8/12/25 obtained more than 60 months from the previous PA Child Abuse clearance dated 1/28/20; DHS FBI clearance dated 5/15/25 obtained more than 60 months from the previous DHS FBI clearance dated 1/28/20; NSOR certificate dated 5/15/25 obtained more than 60 months from the previous NSOR certificate dated 4/30/20. The file for Staff #9 (See LIS Code Sheet) contained a PA State Police clearance dated 10/8/25 which was obtained more than 60 months from the previous PA State Police clearance dated 1/17/20; NSOR certificate dated 5/19/25 obtained more than 60 months from the previous NSOR certificate dated 4/30/20. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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. Correction: The facility acknowledges that required background clearances for Staff #3, Staff #8, and Staff #9 were not renewed within the required 60-month timeframe, resulting in lapses in compliance. Immediate Correction: Staff #3 obtained an updated NSOR certificate on 5/22/25. Staff #8 obtained updated PA State Police clearance on 10/6/25, PA Child Abuse clearance on 8/12/25, DHS FBI clearance on 5/15/25, and NSOR certificate on 5/15/25. Staff #9 obtained an updated PA State Police clearance on 10/8/25 and NSOR certificate on 5/19/25. Documentation of all updated clearances has been placed in each staff member's personnel file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Comply with CPSL/Exp, educ., training at facility (3270.32(a)/3270.192(2)(iii))

The files for Staff #2 and #8 (See LIS Code Sheet) contained Mandated Reporter trainings obtained more than 60 months from the previous Mandated Reporter trainings. The file for Staff #2 contained Mandated Reporter training dated 11/21/25 which was obtained more than 60 months from the previous Mandated Reporter training dated 9/4/20. The file for Staff #8 contained Mandated Reporter training dated 5/28/25 which was obtained more than 60 months from the previous Mandated Reporter training dated 2/25/20. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: The facility acknowledges that Mandated Reporter training for Staff #2 and Staff #8 was not completed within the required 60-month timeframe, resulting in lapses in compliance. Immediate Correction: Staff #2 completed Mandated Reporter training on 11/21/25. Staff #8 completed Mandated Reporter training on 5/28/25. Documentation of the current Mandated Reporter trainings has been placed in each staff member's personnel file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

The file for Staff #6 contained a written evaluation dated 12/2025 which was completed more than 12 months from the previous written evaluation on file dated 1/26/24. The file for Staff #9 contained a written evaluation dated 12/2025. There was no previous written evaluation on file for Staff #9. The file for Staff #10 contained a written evaluation dated 12/2025 which was completed more than 12 months from the previous written evaluation dated 11/22/24. Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: The facility acknowledges that required annual written evaluations were not completed and/or maintained in accordance with regulations for Staff #6, Staff #9, and Staff #10. Immediate Correction: Staff #6 received a written evaluation dated 12/2025, which has been placed in the staff file. Staff #9 received a written evaluation dated 12/2025, and documentation has been placed in the staff file. Staff #10 received a written evaluation dated 12/2025, and documentation has been placed in the staff file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

In the Empower Room, liquid white out was on an open shelf accessible to children. In the 3rd floor kitchenette, wood stain was stored in an unlocked drawer. There was an unlocked custodian cabinet in the hallway on the 3rd floor accessible to children which contained two cans of paint and Goo Gone sealer. There was an unlocked custodian closet in the hallway on the 2nd floor accessible to children which contained bleach and Peroxy cleaner on the floor. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: On 12/19/2025, all hazardous materials were immediately secured: In the Empower Room, liquid white out was removed from the open shelf and placed in a locked cabinet inaccessible to children. In the 3rd floor kitchenette, the wood stain was removed from the unlocked drawer and secured in a locked storage area. The 3rd floor hallway custodian cabinet was locked, and the paint cans and Goo Gone sealer were secured. The 2nd floor hallway custodian closet was locked, and bleach and Peroxy cleaner were secured and removed from the floor. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

110º F or less (3270.69(b))

The water temperature in the Yellow Room was 118°F. The water temperature in the Silver Room was 113°F. The water temperature in the Indigo Room was 119°F. Requirement: Hot water temperature, in areas accessible to children, may not exceed 110° F. Correction: Water temperatures were adjusted immediately to maintain a safe range of 90°F--110°F at all child-accessible sinks. Thermometers were used to verify that all sinks in classrooms and restrooms are within the safe temperature range. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Heat Source (3270.71)

There was a hot water tank accessible to the children in an unlocked cabinet under the sink in the bathroom connected to the Blue room. 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. Correction: The cabinet containing the hot water tank was immediately locked and secured to prevent child access. Staff verified that the hot water tank is inaccessible to children. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Inaccessible to children (3270.75(b))

The first aid kit in the Empower Room was on a low hook and accessible to children. Requirement: A first-aid kit must be inaccessible to children. Correction: The first aid kit was immediately relocated to a high, locked cabinet inaccessible to children. Staff verified that all first aid supplies in the Empower Room are now out of children's reach. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

The ceiling in the Little Gym was leaking. In the corner room past the elevator, the Old Pink Room, the baseboard needed repaired next to the door and under the cabinet on the left wall and the glass in middle window was broken. The blue mats mounted to the walls in the Big Gym were frayed. There were stained ceiling tile in the Green Room, Orange Room, and in the 2nd floor restroom. Requirement: 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: Little Gym: Ceiling leak was assessed and temporarily repaired, with full replacement of roof being scheduled for the coming months to ensure no further leaks occur. Old Pink Room: Baseboard next to the door and under the cabinet on the left wall was repaired. Broken window glass in the middle window was secured until replacement can occur. Big Gym: Frayed blue mats mounted to the walls were repaired. Green Room, Orange Room, and 2nd Floor Restroom: Stained ceiling tiles were replaced; roof was replaced to ensure no further leaks occur. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No peeling paint or plaster (3270.77(a))

There was peeling or damaged paint in the following areas: The wall by the light switch, the left wall, and the right side wall in the corner room past the elevator, the Old Pink Room; The metal display unit in the glass-doored space in the Empower Room was rusty and had flaking paint on the feet; The gray wooden castle, the red metal car, the green wooden pillars, and the green metal climber in the large outdoor play area; The front of the cabinet under the sink in the Pink Room. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: Old Pink Room: Peeling/damaged paint on the wall by the light switch, the left wall, and the right side wall was removed and surfaces repainted with non-toxic, child-safe paint. Empower Room: Rusty/flaking paint on the feet of the metal display unit in the glass-doored space was removed; the unit will be sanded, primed, and repainted with non-toxic, child-safe paint. Outdoor Play Area: A plan for peeling/damaged paint on the gray wooden castle, red metal car, green wooden pillars, and green metal climber to be removed is in place, and surfaces will be repainted with outdoor, child-safe paint when weather permits. Pink Room: Damaged paint on the front of the cabinet under the sink will be repaired and repainted with non-toxic, child-safe paint. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Glass (3270.81)

The glass door in the Empower Room lacked a visual strip or visual identification. Requirement: A visual strip or other visual identification shall be placed on glass located in a traffic area, a child care space or a play space. Correction: A child-safe visual was immediately applied to the glass door to make it easily visible to children and staff. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Lidded waste receptacles (3270.82(i))

The 2nd floor restroom in the hall and the Empower room lacked a lidded waste receptacle. Requirement: A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle. Correction: Lidded waste receptacles were immediately placed in the 2nd floor hallway restroom and the Empower Room. Staff verified that the receptacles are functional and accessible for proper use while remaining child-safe. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Clean and good repair (3270.102(a))

In the Green Room, there was a chair in the circle area with 2 protruding screws on the seat where the cover is torn, and the door hinge on the play kitchen cabinet is broken at the bottom. In the Blue Room, the plastic bin storing the yarn was broken. 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: Green Room: The chair in the circle area with protruding screws and a torn seat was removed from use. The door hinge on the play kitchen cabinet that was broken at the bottom was repaired. Blue Room: The broken plastic bin storing yarn was replaced with a safe, intact storage container. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

2 feet apart (3270.106(f))

Cots lacked 2 feet of space on 3 sides in the Yellow Room (3 cots), Red Room (2 cots), Green Room (3 cots), Orange Room (4 cots), and Violet Room (2 cots). Requirement: 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: Cot arrangements in the Yellow Room (3 cots), Green Room (3 cots), and Orange Room (4 cots) were rearranged to provide at least 2 feet of space on all sides of each cot. Violet and Red classrooms opted to relocate to Big Gym area for rest time to allow for proper spacing of cots. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Services proceeded (3270.123(a)(3))

The file for Child #2 lacked information about the child's growth and development on an approved form. The most recent information about the child's growth and development was reported on 10/3/25 which was more than 6 months from the previous report dated 3/7/25. 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: Growth and development information for Child #2 was updated on an approved form on 10/3/25, and documentation was placed in the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

The emergency contact form for Child #1 lacked the address 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: The emergency contact form for Child #1 was updated to include the complete address of the designated individual, and documentation was placed in the child's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).