St. Francisville United Methodist Church Early Leaning Center

Based on observations and interviews at 11:00 a.m., S1 failed to notify the Department prior to making changes that had an effect on the center’s licensed capacity. During a walkthrough of the center, the Specialist observed a space in the center that was unlicensed, and was being used as a classroom. The Specialist observed (6) four-year-olds in the unlicensed classroom with S11. Corrective Action: Effective 02/04/2026, S1 stated she will move the children to a different area of the center that is licensed, and will contact the Department to add the unlicensed space…

Based on record review and interview at 11:00 a.m., S1 failed to have documentation that within 90 calendar days from the date of hire and prior to assuming sole responsibility for any children, S7 (First Day Present 01/15/2026), failed to have current certification in Adult, Child and Infant CPR and Pediatric Frist Aid. S7’s CPR and Pediatric First Aid certificate was obtained through an unapproved vendor. S1 will schedule a CPR / Pediatric First Aid class to be completed no later than 02/20/2026. Corrective Action: Effective 02/04/2026, S1 stated she will ensure that all CPR and…

Based on record review and interview at 11:00 a.m., S1 failed to ensure each child has written authorization from parents to administer medication at the center. The Specialist requested a medical authorization for C1, 2-years-old, for an Epipen at the center. There was no documentation on file authorizing the center to administer the medication in the case of an emergency. Corrective Action: Effective 02/04/2026, S1 stated she will contact O1, C1’s Mother, to obtain a new authorization form, and moving forward will ensure all children who require emergency medication have an…

Based on record review and interview at 11:00 a.m., S1 failed to ensure that the center maintains a written plan of action for all children who require emergency medication, such as an EpiPen or Benadryl, on file at the center. The Specialist requested a written plan of action for C1, 2-years-old, for an Epipen at the center. There was no documentation of the written plan on file. Corrective Action: Effective 02/04/2026, S1 stated she will contact O1, C1’s Mother, to obtain a new written plan of action, and moving forward will ensure all children who require emergency medication…

Based on record review/interview at 11:00 a.m., S1 failed to have documentation of tornado drills that were conducted at least once per month during the months of March, April, May, and June. There was no documentation that tornado drills had been conducted in the 2025 licensing year. Corrective Action: Effective 02/04/2026, S1, stated that she will conduct annual tornado drills during the months of March, April, May and June each year to ensure compliance with this regulation.

C. Orientation Training - Based on record review and interviews at 11:00 a.m., S1 failed to provide documentation that 1 of 17 staff, received orientation within seven days of the first day present at the center and prior to having sole responsibility for any children. S1 also lacked documentation that 1 of 17 staff received additional orientation within the first thirty days of date of hire. S1 did not have documentation of training for S17 (DOH 09/24/2024). S1 stated each staff member will have proof of orientation training by 12/31/2024.

Based on record review/interview at 11:00 a.m., S1 failed to have documentation that all staff on the premises and accessible to the children have current certification in Adult, Infant and Child CPR through training approved by the Department. 1 of 17 staff members, S11 (DOH 06/03/2024), did not have current certification. S1 stated that she already has a CPR class scheduled for all employees on January 13, 2025 with S11 enrolled.

Based on record review/interviews at 11:00 a.m., S1 failed to have documentation that all staff on the premises and accessible to the children have current certification in pediatric first aid through training approved by the Department. 1 of 17 staff members, S11 (DOH 06/03/2024), did not have current certification. S1 stated that she already has a CPR class scheduled for all employees on January 13, 2025 with S11 enrolled.

1509.A.1. Mandated Reporter: Based on record review/interview at 11:00 a.m., S1 failed to ensure all staff members completed the Mandated Reporter training annually. 8 of 17 staff members, S4 (DOH 10/15/2021), S5 (DOH 03/27/2023), S7 (DOH 10/25/2024), S8 (DOH 03/30/2018), S10 (DOH 02/08/2024), S12 (DOH 03/14/2024), S13 (DOH 10/08/2022), and S17 (DOH 09/24/2024) did not have current certification. S1 stated that she thought that all staff had completed the training, but could not produce documentation indicating that the Mandated Reporter training had been done. S1 stated each staff member…