POCONO FAMILY YMCA

Two written references (3270.192(5))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written reference. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The files of Staff #5, #6 and #7 were missing two letters of written reference. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. The files of Staff #5, #7, #10, #11 (1 reference letter only) and #12 were missing two letters of written reference. Requirement: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Correction: Hire staff w/ 2 letters. Request and receive reference letters. 4/22/26 Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter/Health assessment, TB test (3270.151(a)/3270.192(3))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed during this inspection providing child care and the file was missing a health assessment. A health assessment is required to be on file prior to a staff providing child care. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not update their health assessments at least every 24 months: Staff #9 (previous 8/28/23, current 9/4/25). The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #1 (received 7/23/25) and Staff # 6 (none). An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/14/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #11. Requirement: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis. Correction: Staff hired w/ health assessment. Received #11 health assessment 3/30/26. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each staff person meets quals/Exp, educ., training prior to facility (3270.33(a)/3270.192(2)(ii))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #2, #3 and #4. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5 and #6. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5, #11, #12 and #13. Requirement: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: Request and receive all proof of education for staff by 4/22/26. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. See the code sheet for the date of hire. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #3 was still missing the child abuse clearance. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 3/19/26. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. See the code sheet for the date of hire. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #10 did not apply for the DHS FBI clearance prior to working in a child care role at the facility. Staff #10 did not have the correct signed or dated disclosure statement on file either as required by the CPSL. Staff #11 was working unsupervised at the time of this inspection. Staff #11 was hired using a volunteer child abuse clearance dated 5/23/24, which is not an appropriate clearance to work in child care according to the CPSL. Staff #12 did not have the correct signed or dated disclosure statement on file either as required by the CPSL. 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. Facility Person #10, #11 and #12 may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #10, #11 and #12 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.) 3. For a period of 3 months, the facility shall have no areas of non-compliance related to the CPSL or staff beginning to work prior to approval by the Regional Office. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS ATLEAST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.) Correction: 1. Staff #10, #11 removed immediately. #12 was not working with children yet. #10 no longer works for YMCA. #11 and #12 have completed all clearances prior to working with children. (3/26/26). 2. Send new hire staff files to DHS prior to employee working. Triple check done by YMCA staff prior to working. (7/22/26) 3. Will mainta

Health and Safety Training (3270.31(f))

CONTINUED NON COMPLIANCE A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff persons #1 and #3 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 10/28/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. Staff #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)10. Until such time as the required pre- service trainings are completed, staff #1 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 available to supervise staff #1, staff #1 may not work in a child-care position at the facility. TIERED LIS: 1. All staff must complete required pre-service training within 90 days of hire. The Legal Entity shall demonstrate ongoing compliance with this regulation by providing proof of completion of all pre-service trainings to the Regional Office within 90 days of hire for any staff hired since the last renewal inspection on 10/28/25 or who are hired for the next 3-month period. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEAST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.) 2. For a period of 3 months, the facility shall have no areas of non-compliance of staff working beyond 90 days having not complete the required pre-service trainings as required by regulation. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEICED BY THE REGIONAL OFFICE.) Correction: 1. Send completed new staff files to DHS prior to employee starting. #1 and #3 were supervised until they received pediatric CPR & first aid training (3/26/26). 2. Will maintain compliance & monitoring for the next 3 months. Triple check prior to staff starting and send new hire files to DHS prior to working. (7/22/26) 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))

CONTINUED NON COMPLIANCE A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3, #6 and #8. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3 and #8. 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. TIERED LIS: 1. The facility must not swim until all staff who supervise children at the pool have completed water safety training. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. All staff who supervise children at the pool must have completed water safety training conducted annually by a certified lifeguard. Proof of water safety training for all staff who supervise children at the pool must be provided to the Regional Office for review and approval. (THIS PORTION OF THE PLAN REQUIRES A DATE FOR WHEN THE TRIANING AND PROOF IS COMPLETED AND SENT FOR REVEW.) Correction: 1. Children will not swim until all staff receive water safety. All staff received water safety training on 4/3/26. (3/26/26) 2. All staff will receive water safety training prior to working with children prior to start. (4/3/26) Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

CONTINUED NON COMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #1 has not completed the following required pre-service training, is within 90 days of their date of hire, and was working unsupervised (see LIS code sheet): pediatric first aid/CPR. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 10/28/25. An unannounced inspection occurred at the facility on 3/26/26. Staff #1, #11 and #13 have not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR. Staff #11 and #13 have not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): health and safety topics. Staff #11 and # 13 are within 90 days of their date of hire but were working unsupervised and did not have the following pre-service training completed (see LIS code sheet): mandated reporter. 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. The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). TIERED LIS: 1. Until such time as the required pre- service trainings are completed, staff #1, #11 and #13 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 available to supervise staff #1, #11 and #13, staff #1, #11 and #13 may not work in a child-care position at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. For a period of 3 months, the facility shall have no areas of non-compliance of staff working unsupervised without having completed the required 90-day pre-service trainings. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm that all staff who require supervision are working appropriately supervised. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEAST 3 MONTHS FROM WHEN AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.) Correction: 1. #1 and #11 have completed training, #13 is supervised until final day 4/24 (started 3/26/26). 2. Will maintain compliance & monitoring for the next 3 months. Triple check prior to staff starting and send new hire files to DHS prior to working. (7/22/26) Inspection: Unannounced Monitoring. 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))

A renewal inspection occurred at the facility on 10/28/25. A review of children's files was conducted. Regulation requires consent for emergency medical care for children prior to admission. Child #6 is enrolled and attends the facility, and the file did not contain consent 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 6's parent has provided the consent for emergency medical care when asked and has updated the emergency contact information. consent will remain in the file at all times. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Age and Training/Exp, educ., training at facility (3270.31(e)/3270.192(2)(iii))

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to participate in 12 hours of annual child care training. At the time of the inspection, Staff #8 was only able to provide 8 of the12 required hours of annual child care training for the training year 5/3/24 to 5/3/25. Requirement: A staff person shall obtain an annual minimum of 12 clock hours of child care training. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility. Correction: staff 8 has completed additional trainings as of 12/12 and will forward for review of these completed trainings. Staff will complete 12 hours of annual training and documentation of the completed training will be kept in the staff files for review at any time. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Each staff person meets quals/Exp, educ., training prior to facility (3270.33(a)/3270.192(2)(ii))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #2, #3 and #4. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5 and #6. Requirement: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility. Correction: staff will provide proof of education and a copy will be placed in the file sot staff can be qualified for a child care role at the facility. staff 3 is on leave Staff 5 has filed a translated degree dated 11/16/2025 Staff 6 has submitted her transcript on 10/31/2025 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #3 was still missing the child abuse clearance. See the code sheet for the date of hire. 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. Facility Person #1, #2, #3, #4may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #3 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.) 3. The Director and any Legal Entity Representative involved in the hiring of staff will call the Regional Office (800-222-2108) to schedule the legal entity representative involved in the hiring of staff and the director to participate in the next Existing Provider Training. The Legal Entity and Director will submit documentation to the Regional Office to confirm that they have attended the training. (THIS PORTION OF THE PLAN SHALL HAVE A DATE FOR AFTER THE ATTENDING OF THE EXISTING PROVIDER ORIENTATION.) Correction: 1. Staff will be removed from a child care position at the facility until all proper clearances are obtained and in the staff files. (10/28/25) Staff 1 has an NSOR on file from 8/26/2025 Staff 2 has an NSOR on file from 11/02/205 staff 3 is on leave until summer 2025 Staff 4 is no longer employed 2. The legal entity will submit complete files to the Regional Office for any new hires for a period of three months. New hires will not begin to work in child care until their file has been approved by the Regional Office. (3/19/26) 3. The Director and any Legal Entity Representative involved in the hiring of staff will call the Regional Office (800-222-2108) to schedule the legal entity representative involved in the hiring of staff and the director to participate in the next Existing Provider Training. The Legal Entity and Director will submit documentation to the Regional Office to confirm that they have attended the training. (3/19/26) Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training (3270.31(f))

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff persons #1 and #3 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. Requirement: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)10. Until such time as the required pre- service trainings are completed, staff persons #1 and #3 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 persons #1 and #3, staff persons #1 and #3 may not work in a child-care position at the facility. Correction: Staff will be supervised until they schedule, participate in and compelete pediatric first aid/cpr. A copy of the training certificate will be kept in the staff file for review at any time. staff 1 has cpr on file from 4/24/24 staff 3 is on leave until summer of 2026 Inspection: Renewal. 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))

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3, #6 and #8. 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 will schedule and participate in water safety training. A copy of the completed training will be kept in the staff file. Will send a copy of the completed training for review. Staff 1, & 8 completed training on 10/31. Staff 3 is on leave until summer of 2026 Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Lifeguard/Lifeguard training/supervision (3270.31(e)(4)(iii)/3270.115(a)(6))

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff #7 was identified by the director as the facility's lifeguard used when the children swim. The file of Staff #7 did not contain current lifeguard certification (expired 5/21/25) at the time of the inspection. Requirement: Competence in lifeguard training is demonstrated by completion of lifeguard training, including first-aid training and cardiopulmonary resuscitation (CPR) for child and infant. When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training). TIERED LIS: 1. When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training). Children may not swim until a lifeguard with all appropriate training and file requirements are completed. ((This portion of the plan requires an immediate correction.)) 2. Competence in lifeguard training is demonstrated by completion of lifeguard training, including first-aid training and cardiopulmonary resuscitation (CPR) for child and infant. ((This portion of the plan requires a date when the lifeguard will have completed updated lifeguard certification.)) Correction: 1. Children will not swim until lifeguard training is completed and submitted for review. Staff #7 completed lifeguard training on 11/24/2024. (10/28/25) 2. Children will not swim until lifeguard training is completed and submitted for review. Staff #7 completed lifeguard training on 11/24/2024. A copy will be kept in the staff file for review at any time. Staff will maintain continuous current lifeguard training at all times in the future and a copy of the training certification will be kept in the staff file. (12/10/25) Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to participate in updated fire safety training on an annual basis. The following staff did not participate in annual fire safety training: Staff #9 (previous 9/26/24, current 10/7/25), Staff #7 (previous 3/15/23, no current) and Staff #8 (previous 9/24/24, no current). 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 on 4/14/2025 Staff #7 has been on leave as of 10/31. Will return on 12/19. I will have him complete it then. Will have staff schedule and participate in fire safety training. Will send the competed training for review and will keep a copy in the staff's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #7 has not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training on file expiring 5/23/25. Documentation of updated Pediatric first aid and CPR training is not on file. 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. Until such time as the required pre- service trainings are completed, staff persons #7 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 persons #7, staff persons #7may not work in a child-care position at the facility. Correction: staff will be supervised. staff person has a pediatric first aid/cpr on file dated 1/17/2025. Staff will schedule and participate in pediatric first aid/CPR training. A copy of the completed training will be sent for review and kept in the staff's file for review. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Training regarding plan (3270.27(c))

A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to review the facility's emergency plan on an annual basis. Staff #7 did not review the facility's emergency plan on annual basis (previous review 6/21/21). 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: there is an EAP dated 10/08/2025 in staff #7's file. Will provide for review the EAP. Will ensure staff review the emergency plan at initial hire and annually thereafter. Documentation of the review will be placed in the staff's file. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #1 has not completed the following required pre-service training, is within 90 days of their date of hire, and was working unsupervised (see LIS code sheet): pediatric first aid/CPR. 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. Until such time as the required pre- service trainings are completed, staff person #1 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 person #1, staff person #1 may not work in a child-care position at the facility. Correction: Staff will be supervised until pediatric first aid/CPR is completed. Staff will schedule and participate in pediatric first aid/CPR training. The pediatric first aid/CPR training that is on file dated 4/24/24 will be provided for review. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

12 months prior to service and every 24 months thereafter/Health assessment, TB test (3270.151(a)/3270.192(3))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed during this inspection providing child care and the file was missing a health assessment. A health assessment is required to be on file prior to a staff providing child care. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not update their health assessments at least every 24 months: Staff #9 (previous 8/28/23, current 9/4/25). The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #1 (received 7/23/25) and Staff # 6 (none). See code sheet for the date of hire. Requirement: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis. Correction: staff 6 placed on suspension until they participate in a health assessment and submit their health assessment for the file. 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))

A renewal inspection occurred at the facility on 10/28/25. A review of children's files was conducted. Regulation requires consent for administration of minor first-aid procedures by staff for children prior to admission. Child #6 is enrolled and attends the facility, and the file did not contain consent for administration of minor first-aid procedures by 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 staff has been updated on 10/29/2025 child's family provided consent for administration of minor first-aid procedures by staff. will keep this consent on file at all times. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written reference. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The files of Staff #5, #6 and #7 were missing two letters of written reference. Requirement: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Correction: references have been requested by all staff and submitted by all staff and copies are in their files Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Two written references (3270.192(5))

An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written reference. Requirement: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Correction: Two letters of written reference will be requested and obtained on the staff. These letters will be filed in the staff's file. Inspection: Unannounced Monitoring. 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))

An unannounced inspection occurred at the facility on 8/4/25. A physical site review was conducted. Staff #5 was supervising a group of 9-younger school aged children in the Main Building 2nd Floor SACC Room. Staff #5 allowed three of these children to leave this room to enter the Main Building 2nd Floor Preschool Room to warm up their lunch. These two rooms are adjacent to each other and only separated by a double door. When the three children left the SACC room to enter the Preschool room, Staff #5 was no longer able to provide appropriate supervision as required by regulation. 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 IMMEIDATE CORRECTION DATE.) 2. The Legal Entity / Director will amend the facility's supervision/ratio policy to include the following: - How staff will communicate the transition of children from one room or group to another, while maintaining supervision and ratios. - How staff will ensure appropriate supervision and ratio is maintained during lunch preparation for school-age children. - If transitioning of children is not possible for children to prepare their meals, how staff will prepare and deliver children's lunches in other rooms to ensure supervision and appropriate ratios are maintained in all classrooms. This policy must be submitted to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policy, and documentation must be kept on file at the facility. (THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS POLICY WILL BE WRITTEN, APPROVED AND REVEIWED WITH STAFF.) Correction: 1. Children must be supervised at all times. 8/4/25 2. The Legal Entity / Director will amend the facility's supervision/ratio policy to include the following: - How staff will communicate the transition of children from one room or group to another, while maintaining supervision and ratios. - How staff will ensure appropriate supervision and ratio is maintained during lunch preparation for school-age children. - If transitioning of children is not possible for children to prepare their meals, how staff will prepare and deliver children's lunches in other rooms to ensure supervision and appropriate ratios are maintained in all classrooms. This policy must be submitted to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policy, and documentation must be kept on file at the facility. 9/26/25 Inspection: Complaints- Legal Location. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training. Requirement: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre- service trainings are completed, staff person #4 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 person #4, staff person #4 may not work in a child-care position at the facility. Correction: Staff will be supervised until preservice training is completed. Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires. 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. Facility Person #1, #2, #3 and #4 may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1, #2, #3 and #4 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Northeast Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Northeast Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.) Correction: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1, #2, #3 and #4 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. 8/4/25 2. The legal entity will submit complete files to the Northeast Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Northeast Regional Office. 12/10/25 Inspection: Unannounced Monitoring. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).