Correction check·January 7, 2025

On 1/7/2025, at approximately 9:00AM, Licensing Program Analysts (LPAs) Jonathan Tse and Katie Krenn arrived at the facility to conduct an unannounced Plan of Correction (POC) visit. LPAs met with Director Michelle Doan (D1) and explained the purpose of the visit. Present during the visit was D1, three staff, and eight infants. During an annual visit on 12/4/2024, LPAs issued two citations due to the facility using sleep sacks for sleeping infants and not maintaining complete personnel records for all staff on site available for review. LPAs established a plan of correction with D1 and due dates were agreed upon. The facility completed the plan of correction for sleep sacks and submitted proof of completion to LPAs on 12/5/2024. LPAs did not observe any sleep sacks during the inspection. During today's visit, LPAs reviewed staff records and observed files to be incomplete. Based on record review, LPAs observed that staff files were missing immunization records, signed health screening reports, and documentation of staff qualifications via transcripts. LPAs informed D1 that the deficiency cited on 12/4/2024 for maintaining personnel records was unable to be cleared on this date and that a civil penalty for failure to correct would be issued. LPAs advised that in case of unexpected absences, more than one staff member present on site should have current Pediatric First Aid/CPR training on file. See LIC809-D for deficiency cited regarding personnel files. A plan of correction was discussed and a due date of 2/7/2025 agreed upon. Appeal rights were provided and explained to D1. A notice of site visit was provided and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director Michelle Doan.