BERWICK AREA YMCA DAY CARE

Mixed Age Level (3270.52)

While present at the facility unannounced on 3/13/26 the inspector observed a recording from 3/2/26 that showed staff #1 alone in the young toddler room with nine mixed aged children (4 young toddlers, 4 older toddlers, and 1 preschool aged child) for roughly 30 minutes (approximately 7:03am until 7:38am). Requirement: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff: child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). TIERED LIS: 1. The required staff: child ratios must be maintained at all times. The correction date for this shall be immediate. 2. The director shall develop a ratio policy and procedures for maintaining required staff:child ratios. The ratio policy and procedures will include specific directives for both staff and parents regarding early drop off, late pick up, when to deny children care due to the inability to meet state required ratio, staff call offs and no shows, the proper implementation and utilization of a system to move children as needed for ratio compliment. The ratio policy and procedures must be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once it is accepted by the DHS Northeast Regional Office the director will ensure all staff and parents review the policy and procedures and sign off. The correction date for this should reflect a date that allows for the development and review of the plan as well as time to train staff on this as well as time to update the parents and the parent handbook. 3. The facility will be subject to three unannounced monitoring visits by DHS following the implementation of the ratio policy and procedures. These unannounced monitoring visits will be conducted to ensure that the ratio policy and procedures are being adhered to and that no further instances of noncompliance related to ratio are observed. The correction date should reflect at date that allows for at least 8 weeks from the implementation of the ratio policy and procedures for DHS to complete. Correction: 1. The required staff: child ratios will be maintained at all times. Correction date 3/13/26. 2. The director will develop a ratio policy and procedures for maintaining required staff:child ratios. The ratio policy and procedures will include specific directives for both staff and parents regarding early drop off, late pick up, when to deny children care due to the inability to meet state required ratio, staff call offs and no shows, the proper implementation and utilization of a system to move children as needed for ratio compliment. The ratio policy and procedures will be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once it is accepted the director will ensure all staff and parents review the policy and procedures and sign off. Correction date 6/8/26. 3. The facility will maintain ratio compliance during each of the three unannounced monitoring visits by DHS following the implementation of the ratio policy and procedures as well as moving forward. The facility will have no further instances of noncompliance related to ratio. Correction date 6/8/26. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Aides supervised all times (3270.37(c))

During the course of the unannounced renewal inspection on 10/23/25 the inspector observed staff #1, who qualifies as an Aide, alone in the bathroom with children. Requirement: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor. Correction: This was a naptime bathroom emergency. Policy was verbally communicated to all staff by the director...no aide can be alone with a child for any reason. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Contaminated trash in closed plastic-lined receptacle (3270.67(d))

During the course of the unannounced renewal inspection on 10/23/25 the inspector observed trash cans in the bathrooms that were not lidded as required. Requirement: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. Correction: Unlidded trash can was removed and a lidded trash can was added to the bathroom. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Has all items (3270.75(c))

During the course of the unannounced renewal inspection on 10/23/25 the inspector found that the first aid kit in the Preschool 1 room was missing the required tweezers. Requirement: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves. Correction: Tweezers were added to the first aid kit in Preschool 1 room. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

During the course of the unannounced renewal inspection on 10/23/25 the inspector observed evidence of leaking on the ceiling tiles in the children's bathroom. 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: Ceiling tiles were replaced. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the course of the unannounced renewal inspection on 10/23/25 the inspector observed a broken desk in the Innovations room. Requirement: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs. Correction: Room was locked for the day until desk could be repaired. The repair was made. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Refrigerator (3270.107)

During the course of the unannounced renewal inspection on 10/23/25 the inspector observed a broken thermometer in the refrigerator in preschool 2 room. 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 thermometer was replaced. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the course of the unannounced renewal inspection on 10/23/25 the inspector asked staff #1 and then staff #2 to name and point to the group of children they were assigned to. Both staff #1and staff #2 failed to name a child in the group. Eight children were named and nine were present in care. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan must have an immediate correction date. 2.The legal entity must arrange for staff #1 and #2 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 for when this training is completed. Correction: 1) Children will be supervised at all times. Children will be added to classroom board upon arrival. Children will be counted any time they exit or enter a room. Staff will count children any time they enter a room. Corrected on 10/23/2025 2) DHS inspector approved the following two trainings on 11/5: A) Supervision: Counting Children B) Supervision: What's Required? Staff will complete trainings by 11/7/2025 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #2 was missing work the address and telephone number of the enrolling parent. Requirement: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Correction: Work address and phone number were added to the file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Completed or signed by physician, PA, or CRNP (3270.131(c))

During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #3 and found that it did not have the required signature and date on the health report. Requirement: A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title. Correction: Student only comes on periodic days off from school. Parent was notified of missing information and will bring it on next day of attendance. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

ACIP recommended immunization record (3270.131(e))

During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #1 was missing an initial health assessment that was required within 60 days and not removed from care. Requirement: The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP. Correction: Previous Director did not obtain the required initial health assessment. A current health report with up to date immunization is on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health information (3270.131(a))

During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #1 was missing an initial health assessment that was required within 60 days. Requirement: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. Correction: Previous Director did not obtain an initial health assessment. Child does have a current health assessment on file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.66(b))

While at the facility unannounced on 10/08/25 the inspector observed Dawn dish detergent, 365 hand sanitizer, Coppertone sunscreen, Water Babies sunscreen (labeled Keep out of Reach of Children), sharing the same space as a banana, bread, Nutri Grain bars, and apple sauce. 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: The food items and toxic items were immediately separated. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Surfaces cleaned (3270.135(b))

While at the facility unannounced on 10/08/25 the inspector observed two changing mats (toddler and preschool room) that were cracked allowing the foam underneath to show through. This rendered both mats unable to be cleaned. 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: The director removed both mats immediately. Inspection: Unannounced Monitoring. 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))

While at the facility unannounced on 10/08/25 the inspector observed that a manual test of the fire alarm system was not conducted evidenced by 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: This manual test was completed but not recorded as the director was on vacation. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Water safety/Included in ratio/annual training (3270.31(e)(4)(iv)/3270.115(a)(8))

During the unannounced visit to the Ber Vaughn Pool on 7/30/25 the inspector observed staff #1, #2, # 3, and #4 in swim ratio with children. Staff #1 had an expired water safety training certificate on file. Staff #2, #3, and #4 did not have water safety training. Staff #2 and #4 were provided water safety training following the inspector's visit to the pool. On 7/31/25 the inspector was provided with the water safety certificates via email for staff #2 and #4 dated 7/30/25. This was confirmed by the water safety instructor on 8/20/25. Although requested, the inspector has not received water safety training for staff #3. Requirement: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard. A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction. Correction: Staff #1 and Staff #3 removed from aquatic activity supervision until certifications are completed. Director will implement a training plan that assures all staff who supervise aquatic activities receive training annually. Staff #1 and Staff #3 will be trained in water safety no later than 9/5/25. Inspection: Swimming. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original container (3270.133(1))

During the unannounced visit to the Ber Vaughn Pool the inspector observed two inhalers and an Eppi-Pen missing their original containers. Requirement: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received. Correction: Director will insure hat all medications are stored and maintained in original containers in which they are received. Inspection: Swimming. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Name on bottle (3270.133(3))

During the unannounced visit to the Ber Vaughn Pool the inspector observed two inhalers and an Eppi-Pen missing the names of the children for whom the medications were intended. Requirement: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container. Correction: Director will insure all medication containers are identified with the name of the child for whom the medication is intended and medications are only administered to the child whose name appears on the container. Inspection: Swimming. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Original label (3270.133(5))

During the unannounced visit to the Ber Vaughn Pool the inspector observed an expired inhaler (exp 6/2025) for child #1. Requirement: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label. Correction: Director will insure that all medications stored in accordance with 3270.133(5). Inspection: Swimming. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Continued Non-Compliance: During the annual unannounced renewal, the inspector reviewed the file for staff #2 and found that this staff was working in direct care with children did not have a completed FBI clearance on file, Pa State Police clearance was not obtained until 8/4/24, a Pa Child Abuse clearance was not obtained until 8/9/24, and a NSOR was not obtained until 8/7/24. Staff #3 was working in direct care with children and did not have an NSOR and obtained a PDE FBI and not the required DHS FBI. Staff #7 was working in direct care with children and did not have an FBI on file until 6/5/24. Staff #9 was working in direct care with children and did not have a Pa State Police clearance on file or an NSOR. Staff #10 was working in direct care with children and did not obtain a NSOR until 12/20/23. Staff #13 was working in direct care with children and did not obtain a NSOR until 9/4/24. Staff #14 was working in direct care with children and did not obtain an FBI until 6/27/24, and an NSOR until 8/7/24. Staff #15 was working in direct with children and did not obtain an NSOR until 10/9/24. Staff #16 was working in direct care with children and did not have an FBI clearance until 10/18/24, and an NSOR until 9/16/24. Staff #17 was working in direct care with children and did not obtain a PA State Police clearance until 4/19/24, and an FBI clearance until 4/22/24, and an NSOR until 11/7/24. Staff # 18 was working in direct care with children and did not obtain a PA Child Abuse until 8/16/24, an FBI until 8/15/24, and an NSOR until 8/23/24 (see LIS code sheet for DOH). The facility's acceptable plan of correction indicated the correction would be implemented by 2/14/25. On 5/21/25 an unannounced inspection was conducted at the facility. The inspector observed staff #1 working directly with children during this inspection. The inspector reviewed the file for staff #1and noted that this staff was missing required out of state clearances since hire (see LIS code sheet) and self-reported that they were working directly with children since the end of February 2025 (exact date was not provided). Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 1 may not work in a childcare position at the facility. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 may not work in a childcare position at the facility. 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. TIERED LIS 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The correction date for this portion of the plan must be immediate. 2. The facility director, VP of Operations, and any other persons involved in the hiring of staff must arrange for and attend an Existing Provider Training held in the Northeast Regional Office of DHS, Scranton Office. To register for this required training, you must call the Northeast Regional Office at 1 800 222 2108.The correction date for this portion of the plan must coincide with the next Existing Provider Training which is being held on 8/6/25. 3. In order to demonstrate compliance in this area, the director or legal entity representative will send completed staff files for all new hires f

Infant/Toddler Stimulation (3270.112)

On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 an infant was left in a bouncer from drop off at 7:44am until 8:36am with no contact from staff including being spoken to, played with or otherwise cared for. Requirement: Infants and toddlers shall be provided stimulation by being held, rocked, talked to, played with and carried. Correction: Staff member was terminated 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))

Continued Non-Compliance: On 2/14/25 an unannounced, self-reported complaint investigation was conducted at the facility. It was learned that on 2/7/25 at roughly 3:33pm, child #1 was, in fact left alone in the preschool room for roughly four minutes after staff #1 left the room with another child to go to the gym. Child #1 was found by a parent and brought to the staff's attention. An acceptable plan of correction was received with a correction date of 2/10/25. On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 and 3/3/25 staff #2 was observed on their phone from 8:18am until 8:22am, was observed several times looking through the window, watching her child in the classroom next door, for several minutes each time, observed leaving the infant room and the group of five infants with staff #3 alone. 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. 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. Tiered LIS: 1. Children must be supervised at all times. The correction date for this must be immediate. 2. The legal entity must arrange for all staff to receive a minimum of three hours of training regarding Supervision. The training must be PQAS approved, in-person, and outside of childcare hours. The legal entity must receive approval from the DHS Northeast Regional Office regarding the training content prior to scheduling the training. The operator must provide a correction date for when this training will be completed. 3. The facility director will develop and implement a supervision policy that will ensure staff fully understand their responsibility regarding the supervision of children at all times. This policy must be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once this policy is accepted by the DHS Northeast Regional Office the director will ensure all staff and facility persons sign off on this policy as well as all new hires moving forward. The operator must provide a correction date, which is after completion of the training, for when this portion of the plan will be completed. Correction: 1. 3/7/25 correction date. Employee was terminated. Each staff person will be assigned the responsibility for supervision of specific children. The staff person will know the names and whereabouts of the children in his assigned group. The staff person will be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. 2. 5/1/25 correction date. The legal entity will arrange for all staff to receive a minimum of three hours of training regarding Supervision. The legal entity will obtain approval from the DHS Northeast Regional Office regarding the training content prior to scheduling the training. The operator will provide a correction date for when this training will be completed. 3.5/15/25 correction date. The facility director will develop and implement a supervision policy that will ensure staff fully understand their responsibility regarding the supervision of children at all times. This policy will be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once this policy is accepted by the DHS Northeast Regional Office the director will ensure all staff and facility persons sign off on this policy as well as all new hires moving forward. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written statement/New foods - parent's consent (3270.166(1)/3270.166(2))

On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned through direct discussion and observation of and with staff #2 and staff #3 that there were no written parental statements giving the formula and feeding schedules for any of the infants in care and that there was no consultation with any of the five infant's parents on new foods being introduced. Requirement: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent. New foods shall be introduced to an infant only after consultation with the child's parent. Correction: Staff #2 was terminated as she was the lead teacher in this room. Written feeding schedules were obtained from parents of children enrolled in the infant room. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Disposable nursers or parents (3270.166(3))

On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned through direct discussion and observation of and with staff #2 and staff #3 that both staff handwashed bottles for reuse throughout the day for all five infants in care. Requirement: Disposable nursers shall be used for infants unless bottles are provided by the parent or unless a commercial dishwasher is used by the facility. Correction: Staff #2 was terminated. All infant room staff were spoken to concerning handwashing bottles and only disposable nursers should be used and at no time should a bottle be washed and reused. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Six-months-old held (3270.166(5))

On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage that on 2/28/25 and 3/3/25 child#1, #2, #3, #4, and #5 were all present in the infant room with staff #2 and #3. The video clearly showed four of the five infants in baby bouncers, with bottles propped by blankets, that were implemented by staff #2. One infant was being held by staff #3 while being fed. Two of the five infants were under six months old (Please refer to the LIS Code Sheet for DOB). Requirement: An infant 6 months of age or younger shall be held while being bottle fed. Correction: Staff #2 was terminated. All infant room staff were informed of this regulation and the safety concerns of this action feeding infants under 6 months. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).