OUR CHILDRENS CENTER

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

Staff #1 had an NSOR dated 2/26/26, which was not completed prior to working with children. Staff #1 could not produce the previous NSOR to verify that staff #1 did not have a lapse of time between clearances. Staff #3 had an NSOR dated 3/5/26, which was not completed prior to working with children. Staff #3 could not produce the previous NSOR to verify that staff #3 did not have a lapse of time between clearances. Staff #4 had an FBI clearance dated 5/23/25. Staff #4 could not produce the previous FBI clearance to verify that staff #4 did not have a lapse of time between clearances. Staff #5 had an NSOR dated 3/5/26, which was not completed prior to working with children. Requirement: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). S A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Correction: Staff #1 requested her previous NSOR from her former employer, and then provided to us. We sent to DHS Inspector on 4/23/26. Staff #3 requested her previous NSOR from her former employer, and then provided to us. We sent to DHS inspector on 4/8/26. Staff #4 requested her previous FBI clearance and then provided to us. We sent to DHS inspector on 4/23/26. Staff #5 is unable to produce a previous NSOR. Our new procedures will not allow employees to add to our payroll or begin work without clearances in hand. 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))

Staff #1 does not have a health assessment or TB screening on file. Requirement: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. 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 #1 requested these from her former employer and they did not respond. Staff #1 completed a new health assessment with TB screening and provided it to us. This was on file for DHS Inspector but we do not have the older one in order to prove compliance at hire in 5/25. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Health and Safety Training - Pediatric First Aid and CPR (3270.31(f)(10))

Staff #2 had Pediatric CPR completed on 1/12/26, which was not completed within 90 days of hire. Staff #2 had CPR at initial employment but the course completed was not an approved course. Requirement: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Correction: We did not realize at hire that Infant & Child was not acceptable. Staff #2 now has a correct Pediatric CPR from 1/12/26 and we will ensure that all new employees have certification using an approved course. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Director or designated staff person responsibility/Every 60 days (3270.94(a)/3270.94(a)(1))

A fire drill was documented as completed on 11/12/25 and again on 1/15/26, which is greater than 60 days apart. Requirement: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the critera specified in §3270.95Ia)(1)- (a)(9) are met The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days. Correction: We will move to a 45-day frequency rather than 60-day period. 45 day frequency will ensure that we do not draw close to the legal 60-day and then run into bad weather (which is what happened in January 26). We have now designated our new Administrative Coordinator as the point person for maintaining compliance rather than the Head of School. Inspection: Renewal. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

Supervised at all times (3270.113(a))

Self-Report of child left unsupervised on 9-11-25. Child #1 was found in the bathroom unsupervised for approximately 1 minute, from the time the line of children and staff moved out of the nap room and reached the top of the stairs until the Director went into the room (after they exited) to turn off the lights in the room and Child #1, was left behind in the bathroom changing her clothes while the rest of the nap group returned up the stairs. When staff reached the top of the stairs, they realized that their count was off, at the same time that the Director moved to the back of the nap room to turn off lights and found Child #1 still working on changing her clothes. 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. Children must be supervised at all times. The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. Correction: At the end of Primary nap, we are adding a third teacher (one beyond necessary ratio) to help ease the logistics of wake up, toileting, cleaning beds, and transition upstairs. This staff member will be admin/group supervisor level. As children are finished with after nap tasks, they will gather on the carpet for songs and books with the third teacher. Once all children are gathered and counted on the rug, teachers will visually sweep the back bathrooms, turning off lights and closing the doors once checked. Rather than transitioning in a single large group and then dividing into the two classrooms upstairs, the 1st and 2nd teacher will each call their primary group to line up, verbally and visually counting the students in their care. Each group will leave the Big Room separately and take the separate stairwells closer to their respective classrooms upstairs. Teachers will repeat a verbal and visual count at each transition point in the building (doorways, corners, stairwells). All staff (full building) met with the Head of School within 24 hours of the incident to talk through what happened, review policy and procedure, and discuss ways to help one another avoid any recurrence. This was again presented at the next month's full staff meeting. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).

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

Self-Report of child left unsupervised on 9-11-25. Child #1 was found in the bathroom unsupervised for approximately 1 minute, from the time the line of children and staff moved out of the nap room and reached the top of the stairs until the Director went into the room (after they exited) to turn off the lights in the room and Child #1, was left behind in the bathroom changing her clothes while the rest of the nap group returned up the stairs. When staff reached the top of the stairs, they realized that their count was off, at the same time that the Director moved to the back of the nap room to turn off lights and found Child #1 still working on changing her clothes. Child #1 was in Staff #2's Primary Care Group. Requirement: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. Correction: At the end of Primary nap, we are adding a third teacher (one beyond necessary ratio) to help ease the logistics of wake up, toileting, cleaning beds, and transition upstairs. This staff member will be admin/group supervisor level. As children are finished with after nap tasks, they will gather on the carpet for songs and books with the third teacher. Once all children are gathered and counted on the rug, teachers will visually sweep the back bathrooms, turning off lights and closing the doors once checked. Rather than transitioning in a single large group and then dividing into the two classrooms upstairs, the 1st and 2nd teacher will each call their primary group to line up, verbally and visually counting the students in their care. Each group will leave the Big Room separately and take the separate stairwells closer to their respective classrooms upstairs. Teachers will repeat a verbal and visual count at each transition point in the building (doorways, corners, stairwells). All staff (full building) met with the Head of School within 24 hours of the incident to talk through what happened, review policy and procedure, and discuss ways to help one another avoid any recurrence. This was again presented at the next month's full staff meeting. Inspection: Self-Reported Non Compliance. Source: PA DHS COMPASS provider search (compass.dhs.pa.gov).