Tender Care Learning Center/wexford

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: In the Infant room, the following cribs were observed to not have at least 2ft of space on 3 sides while in use: four infants were observed inside their individual cribs that were lined up vertically against the wall with approximately one foot or less of space on either side of the cribs.

Correction Required: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: At approximately 1:00pm, during naptime in the PreK Room, one staff and 16 preschool age children were observed. During the onset of a supervision/ratio check, when staff were asked to identify and name all of the children who they were responsible for Staff person #4 identified and named only 6 children thus leaving the other 10 children unaccounted for. When asked who was responsible for the 10 unnamed children Staff person #4 said Staff person #7, who was out of the room on their break, was responsible for those children. Staff person #7 was observed to not be physically present with their assigned group of children.

Correction Required: 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.

Regulation: 3270.31(e)(4)(ii)

Description: Fire safety - 1 yr.

Noncompliance Area: The staff file for Staff person #2 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 9/17/25 and 8/22/24. The staff file for Staff person #3 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 9/9/25 and 1/15/24.

Correction Required: 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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The staff file for Staff person #1 contained a current Child Abuse clearance dated 3/1/25 and a current FBI clearance dated 2/18/25 both of which were not renewed within 60 months of the previously dated 2/7/20 Child Abuse clearance and 2/6/20 FBI clearance expiring. The staff file for Staff person #4 contained a current Child Abuse clearance dated 11/25/25 which was not renewed within 60 months of the previously dated 11/6/20 Child Abuse clearance expiring. The file for Staff person #5 (See IS Code Sheet), who has resided out of state within the previous five years, was observed to lack a Child Abuse and Neglect Check as well as a Sex Offender Check.

Correction Required: 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 #5 may not work in a childcare position at the facility.

Regulation: 3270.36(b)(5)/3270.192(2)(ii)

Description: HS/GED + 2 yrs/Exp, educ., training prior to facility

Noncompliance Area: The staff file for Staff person #6 who is functioning as an Assistant Group Supervisor, contained multiple employee verification forms however the hours worked were not specified therefore unable to determine if they have two years of experience working with children.

Correction Required: 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.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: In the PreK Room two ceiling tiles above the doorway were observed to not be kept clean as evidence by having water spots from a previous leak that has since been repaired.

Correction Required: 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.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: In the infant room, where two staff and five infants were present, the following lapses in supervision were observed on video footage recorded on 2/3/26. Two infants occupied cribs, one occupied a motion swing, and Child #1 and another infant were in a gated play area by themselves. Staff person #1 was observed across this play area, leaning up against the counter preoccupied with their phone while Staff person #2 rocked an infant and had their back turned to the play area. Child #1 can be seen pushing themself up and leaning on a wooden activity cube. The infant then took their left hand off of the wooden activity cube, loses their balance and fell, with their face/mouth hitting the solid wiring on the top of the toy, resulting in their head jolting backwards resulting in an injury to the child's frenulum. Due to Staff person #2's positioning with their back turned and Staff person#1's preoccupation with their mobile phone, it is determined that neither staff were able to see, direct or assess Child #1, and inadequate supervision contributed to the injury of the child.

Correction Required: TIERED LIS: 1.) Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. The correction date for this portion of the plan will be immediate. 2.) The facility will compose a specific policy for the use of personal and facility-issued mobile devices during work hours. The policy should include examples of acceptable (if any) and unacceptable reasons for using personal and facility- issued mobile devices; when and where staff can use their personal and facility-issued mobile devices; consequences for personal mobile device use during work hours and inappropriate usage of facility-issued devices. The policy will be submitted to the Regional Office for review. Once the policy is finalized, the staff handbook shall be updated. Currently employed staff will sign off that they have read and understand the policy. The facility may seek technical assistance from the ELRC for creation of the policy, if desired. The correction date for this part of the plan shall be within one month of acceptance of this plan of correction. 3.) The legal entity will ensure that all facility persons complete the PA Required Health and Safety for Centers-Group Child Care Part 1 and PA Required Health and Safety for Centers-Group Child Care Part 2 trainings found on Penn State Better Kid Care website within 21 calendar days of the acceptance of this plan of correction. All facility persons who have already completed PA Required Health and Safety for Centers-Group Child Care Part 1 and PA Required Health and Safety for Centers-Group Child Care Part 2 trainings will be required to take the trainings again and provide documentation of completion after the date of the acceptance of this plan of correction. Once all facility persons have completed these required trainings, the legal entity will submit the training certificates for all facility persons to the Western Regional Office within 5 business days of the last date of completion. The operator will provide a date by which these trainings will be completed. 4.) The director, assistant director, and representative(s) from executive leadership will participate in a virtual technical assistance session with the senior health management staff at PA Key to conduct a Root Cause Analysis to determine "next steps" for improving systemic issues regarding supervision and risk management. Discussions can include, but are not limited to, the topics of: active supervision, classroom management, anticipating children's movements, response to child injuries, and creating a safe environment for caring for infants. Prior to attending the TA meeting, the director, assistant director, and representative(s) from executive leadership will be required to watch the video of the incident from 2/3/26 and come to the meeting prepared to discuss. The correction date for this portion of the plan will be based on when this technical assistance training is to be scheduled. 5.) Subsequent to the technical assistance (TA) session, a 2-hour supplemental virtual training regarding infant care will be provided by the PA Key, based on the needs identified during the TA session. At minimum, any staff that can be anticipated to work with infants will attend this training. This training can be counted towards the annual regulatory training requirements in 3270.31(e), as long as proper documentation is obtained. The correction date for this portion of the plan will be after the date of the TA session and when this training is to be scheduled.

Regulation: 3270.131(b)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The child file for Child #1, who is a preschool age child, was observed to contain an updated health report dated 11/24/25 which was conducted more than 12 months from the previously dated 10/4/24 health report on file.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.151(a)/3270.192(3)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: The staff file for Staff person #1, contained a current health assessment dated 2/7/24 which was conducted more than 24 months from the previously dated 1/9/22 health assessment on file.

Correction Required: 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.

Regulation: 3270.95(a)/3270.95(b)

Description: Devices must be compliant/Director or designated staff person ensure compliance

Noncompliance Area: The facility's documentation regarding the testing of their fire detection system by a fire safety professional was deemed unacceptable as it did not include the results of the testing.

Correction Required: 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.

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: The refrigerator in the PreK Room was observed to lack a thermometer.

Correction Required: 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.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 1:25pm, during naptime in the PS Readiness Room where staff was positioned in the room they could not adequately supervise one of the napping children due to a child's wooden shelving unit obstructing the Staff's ability to see and assess that child who was napping on the other side of that shelving unit.

Correction Required: 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.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: The child file for Child #1 was observed to contain a current financial agreement form that lacked the child's admission date.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: In the PS Readiness Room, a bottle of child's acetaminophen was observed to lack the name of the child for whom the medication was intended for.

Correction Required: 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.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: In the PS Readiness Room, a bottle of child's ibuprofen was observed to have expired as of 11/2024.

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.