MALVERN ACADEMY LLC

Toddler - 50 sq ft/child (3270.62(b)(2))

During the complaint investigation conducted 5/12/26, there were 24 children present in the outdoor play space with staff person #2, # 3, #4 and #5, exceeding the capacity of the play space which is 19. Requirement: The minimum outdoor or indoor play space required per young or older toddler is 50 square feet. Correction: Staff have been notified that they are not to exceed more than 19 children on the playground. Staff have also been notified to maintain the maximum group sizes at all times. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Mixed Age Level (3270.52)

During the complaint investigation conducted 5/12/26, staff persons #2, #3, #4 and #5 were observed grouped together with 24 children and exceeding the maximum group size in the outdoor play space with the youngest child being a young toddler and the oldest child being prekindergarten age. 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). Correction: Staff have been notified that they are not to exceed the maximum group size at any given time. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

HS/GED + 2 yrs/Exp, educ., training prior to facility (3270.36(b)(5)/3270.192(2)(ii))

During the complaint investigation conducted 5/12/26, the record reviewed for staff #1 and #2 did not include verification of childcare experience for the position performing (Assistant Group Supervisor). Requirement: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Verification of childcare experience will be obtained for missing staff. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Physician name, address, phone (3270.124(b)(2))

During the renewal inspection conducted 4/1/26, the emergency contact reviewed for child #1 did not include the telephone number of the child's physician or source of medical care. Requirement: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Correction: Family will complete the form to its entirety. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the renewal inspection conducted 4/1/26, the continuity of operations reviewed did not include backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster 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: Director will create a continuity of operations that includes required information such as back up or retrieving health and other key records/ files and managing financial issues such as paying employees and bills during the aftermath of the diaster. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Locked or inaccessible (3270.66(a))

During the renewal inspection conducted 4/1/26, Bleach and water spray, sanitizing spray and diaper rash cream was observed in an open unlocked closet underneath the changing table in the toddler room. Requirement: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Correction: Regional director created a toxins policy to review with the staff. Policy will be reviewed with the staff by the regional director. Toxins were locked away immediately the day of inspection. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Has all items (3270.75(c))

During the renewal inspection conducted 4/1/26, the first aid kit reviewed in the second-floor preschool room did not include scissors. The first aid kit reviewed in the PreK 1 and 2 childcare spaces on the second floor did not include disposable gloves, soap or scissors. 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: A list of required items will be placed in all first aid kits. All first aid kits will be properly stocked. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

No peeling paint or plaster (3270.77(a))

During the renewal inspection conducted 4/1/26, chip paint was observed on the gray wall near the sink in the 2-year-old bathroom. Chip paint was also observed on the corner of the walls near the infant crib in the Infant 2 childcare space. Chip paint was observed on the purple wall in the PreK 1 room, on the second floor and also on the mint green wall in the PreK 2 classroom on the second floor. Requirement: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility. Correction: The chipped paint will be touched up. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the renewal inspection conducted 4/1/26, the emergency contact reviewed for child #2 did not include the address and telephone number 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: Director and administrative assistant will have the family complete a new emergency contact form. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Child's hands washed (3270.134(a))

During the renewal inspection conducted 4/1/26, Staff person #1 did not ensure the child that was getting their diaper changed, washed their hands after being diapered. Requirement: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. Correction: Staff member will complete Infant-Toddler Care: Daily Routines on Better Kid Care. Staff will be shown by director or administrative assistant on how to properly follow diaper changing procedures. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Adult Hygiene (3270.152)

During the renewal inspection conducted 4/1/26, Staff person #1 did not wash their hands after changing a child's diaper. Requirement: A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child. Correction: Staff member will complete Infant-Toddler Care: Daily Routines on Better Kid Care. Staff will be shown by director or administrative assistant on how to properly follow diaper changing procedures. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Similar Age Level (3270.51)

Durning the unannounced inspection conducted 1/21/26, it was found that staff #1 was left alone with 12 older toddlers during nap when an incident occurred where child # 1 was injured. (One child was up actively moving around and roaming the classroom when child #1 was injured while laying on their cot). 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 #1 was immediately terminated after review of video. Inspection: Incident Investigation. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

Durning the unannounced inspection conducted 1/21/26, It was observed that staff person # 1 was not supervising the children in her assigned group at all times when child # 1 was injured. Staff person # 1 was observed via footage reviewed, to be looking at her cellular phone at the time of the incident. Requirement: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Correction: Employee was immediately terminated after review of video. Inspection: Incident Investigation. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Inpatient hospitalization or ER treatment of child (3270.20(a)(1))

During the complaint investigation conducted 9/29/25, it was found that the operator did not notify the regional office within 24 hours of an incident that occurred on 8/21/25 in which child # 1 sustained an injury at the facility while playing on the outdoor play area equipment (seesaw) which required emergency treatment. Requirement: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment. Correction: Staff #1 is no longer employed with our facility with all previous contracts voided. Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Written consent/Consent for emergency medical care required prior to admission (3270.124(b)(4)/3270.182(3))

During the renewal inspection conducted 4/2/25, the emergency contact reviewed for child #2 did not include the written consent signed by a parent for emergency medical care. Requirement: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. Correction: Child 2 emergency contact review has been signed by the parent for medical care. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Pick-up and drop-off points (3270.171(a))

During the renewal inspection conducted 4/2/25, upon request there was no verification available for review to verify the facility notified local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the childcare facility. Requirement: An operator shall notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility. Correction: The director has written the locations of the facility and the programs use of pedestrians and vehicle routes. the director will email the local authorities annually Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Emergency plan (3270.27(a)(6))

During the renewal inspection conducted 4/2/25, upon request there was no emergency drill log available for review to verify the facility conducts annual emergency drills. Requirement: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility. Correction: Emergency drill log has been placed in the directors office. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Consent for administration of minor first-aid required prior to admission (3270.182(5))

During the renewal inspection conducted 4/2/25, the emergency contact reviewed for child #2 did not contain signed parental consent for administration of minor first-aid procedures by facility staff. Requirement: A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission. Correction: child 2 parents has signed the missing section on the emergency contact. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Safe routes posted (3270.171(c))

During the renewal inspection conducted 4/2/25, written notification of safe routes was not posted in a conspicuous location in the childcare facility. Requirement: Written notification of safe routes shall be posted by the operator at a conspicuous location in the childcare facility. Correction: Written notification of safe routes has been posted in the childcare facility Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Adult Hygiene (3270.152)

During the renewal inspection conducted 4/2/25, Staff person #5 did not was their hands after changing child #1 diaper. Requirement: A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child. Correction: Staff 5 was corrected on hands washing after diapering of a child Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Child's hands washed (3270.134(a))

During the renewal inspection conducted 4/2/25, staff person #5 did not wash child #1 hands after diapering. Requirement: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. Correction: staff 5 was corrected on the diaper changing steps and to ensure all children hands are washed after every diaper change Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Building Surfaces (3270.76)

During the renewal inspection conducted 4/2/25, water stains were observed on the ceiling tile in the prekindergarten and school-age childcare space on the 3rd floor. 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: The ceiling tiles have been replaced Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Staff evaluations (3270.34(a)(6))

During the renewal inspection conducted 4/2/25, upon request there was no verification available for review to verify staff person #3 and #4 received a minimum of one evaluation every 12 months (see code sheet for hire date). Requirement: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. Correction: Staff 3 and 4 have received an evaluation Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

During the renewal inspection conducted 4/2/25, the file reviewed for staff person #1 did not include an out of state criminal history or national sex offender's registry. The mandated reporter training reviewed for staff person #4 was not an acceptable training. (See code sheets for hire date). Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 1-- may not work in a childcare position at the facility. 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 #4 must complete the required mandated reporter training and must be supervised at all times by an assistant group supervisor, primary staff person or higher who has completed the required mandated reporter training. Correction: Staff 1 has conducted an out of state criminal history background check, and a national offenders check, staff 4 will complete mandated reporter training. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

During the renewal inspection conducted 4/2/25, upon request the emergency plan training verification reviewed for staff person #1, #3 and #4 were not updated on an annual basis. Staff person #1 and #3 last dated 5/12/23, staff person #4 last dated 3/4/24. Staff person #2 did not have emergency plan training verification available for 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: staff 1,2,3,4 have conducted an updated emergency planed training Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).