DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

FAMILY HOME INSPECTION REPORT
Facility Information

PAPER MOON NURSERY LLC

002692706

(573) 289-2151

551 SOUTHAMPTON DR
COLUMBIA
MO  65203-3057

PAPER MOON NURSERY LLC



 

GERNER, MELISSA ANNE

director@papermoonelc.com


LEKEL LYONS

BIRTH - 2 YEARS

8

FAMILY HOME

8 CHILDREN UNDER 24 MONTHS; UP TO 8 CHILDREN IN CARE, ALL CHILDREN MAY BE UNDER AGE 2 WITH 2 ADULT CAREGIVERS; IF ONLY 4 CHILDREN PRESENT, ALL CHILDREN MAY BE UNDER AGE 2 WITH 1 ADULT CAREGIVER; UP TO 6 CHILDREN IN CARE NO MORE THAN 3 CHILDREN UNDER AGE 2 WITH 1 ADULT CAREGIVER; UP TO 8 CHILDREN IN CARE NO MORE THAN 2 UNDER 2 W/ 1 CAREGIVER
 
Inspection Information

09/10/2021

11:37 AM

12:34 PM

UNANNOUNCED

COMPLIANCE MONITORING

2407950173


DocumentDocument-Date
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 01/28/2021
ANNUAL DECLARATION 01/28/2021
APPLICATION 11/20/2019
ASSISTANT APPROVAL REQUEST 03/06/2018
ARTICLES OF INCORPORATION 01/19/2018
CHILD CARE/DISCIPLINE POLICIES 03/06/2018
DISASTER AND EMERGENCY PREPAREDNESS PLAN 03/06/2018
DIAGRAM/INDOOR 03/06/2018
EQUIPMENT LIST 02/08/2018
POLICIES 02/08/2018
DAILY SCHEDULE 02/08/2018
LLC OPERATING AGREEMENT 03/06/2018
SAFE SLEEP POLICY 02/08/2018
SAMPLE FORMS 02/08/2018
OWNER/PROVIDER REFERENCES 03/06/2018
SAMPLE WEEKLY MENU 02/08/2018
SANITATION INSPECTION 11/20/2020
LLC ARTICLES OF ORGANIZATION 01/19/2018
FIRE/SAFETY INSPECTION 12/08/2020




Inspection determined facility to be in compliance with licensing rules.
Open Violations: 22
NOTE
The licensee is responsible for compliance with all licensing rules, including but not limited to the rules listed on this compliance report form.
Attendance at Time of Inspection
Total Staff 3
Total Children 7
StaffChildClass AgeNote
3 7 INFANTS AND TODDLERS Ashlyn Carter, Sherona Lewis, and Kortney Strecker were the caregiver of children ages 9-16 months

 
19 CSR 30-61.025 Organization and Administration
Compliance
19 CSR 30-61.045 Licensing Process
Compliance
19 CSR 30-61.055 Annual Requirements
Compliance
19 CSR 30-61.085 Physical Requirements of the Family Day Care Home
Compliance
19 CSR 30-61.086 Fire Safety
Violation
 Provider Comments
Violation
Requirements of 19 CSR 30-61.086 Fire Safety were not met as evidenced by fire drills were not held at least one time each month.
Licensing Rule Reference
19 CSR 30-61.086 Fire Safety 2 (C) states: Child care staff shall conduct at least one (1) fire drill each month and a disaster drill at least every three (3) months. The disaster drills shall include tornado drills. The provider shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building, and number of children present during the drill.
Correction Required
Fire, tornado, and other disaster drills shall be completed and recorded as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
Requirements of 19 CSR 30-61.086 Fire Safety were not met as evidenced by the disaster and tornado drill was not held at least one time every three months.
Licensing Rule Reference
19 CSR 30-61.086 Fire Safety 2 (C) states: Child care staff shall conduct at least one (1) fire drill each month and a disaster drill at least every three (3) months. The disaster drills shall include tornado drills. The provider shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building, and number of children present during the drill.
Correction Required
Fire, tornado, and other disaster drills shall be completed and recorded as required.

Correction Verification
Submit Documentation

Compliance Date

19 CSR 30-61.090 Disaster and Emergency Preparedness
Compliance
19 CSR 30-61.095 Furniture, Equipment and Materials
Compliance
19 CSR 30-61.105 The Child Care Provider and Other Child Care Personnel
Compliance
19 CSR 30-61.115 Day Care Family and Household
Compliance
19 CSR 30-61.125 Medical Examination Reports
Violation
 Provider Comments
Violation
A medical examination report was not on file for assistant(s): Sherona Lewis.
Licensing Rule Reference
19 CSR 30-61.125 Medical Examination Reports (1) (D) states: Assistants who are employed or volunteer more than five (5) hours per week shall have a medical examination report on file within thirty (30) days of beginning work in the home.
Correction Required
Medical reports shall be on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
A medical examination report did not include a completed Risk Assessment for Tuberculosis form for Sherona Lewis .
Licensing Rule Reference
19 CSR 30-61.125 Medical Examination Reports (1) (E) . states: Medical examination reports shall include a “Risk Assessment for Tuberculosis” form, included herein, completed and signed by a health care professional, as provided by the Missouri Department of Health and Senior Services (MDHSS). If the person has signs or symptoms of tuberculosis, or risk factors for tuberculosis, then testing for tuberculosis shall occur.
Correction Required
TB reports shall be on file as required.

Correction Verification
Submit Documentation

Compliance Date

19 CSR 30-61.135 Admission Policies and Procedures
Compliance
19 CSR 30-61.145 Nighttime Care
Compliance
19 CSR 30-61.155 Overlap Care of Children
Compliance
19 CSR 30-61.165 Emergency School Closings
Compliance
19 CSR 30-61.175 Child Care Program
Compliance
19 CSR 30-61.185 Health Care
Violation
 Provider Comments
Violation
Requirements for immunization reports on file were not met as evidenced by 1 immunization record(s) was/were not on file .
Licensing Rule Reference
19 CSR 30-61.185 Health Care (4) (A) states: No child shall be permitted to enroll in or attend any day care facility caring for ten (10) or more children unless the child has been adequately immunized against vaccine preventable childhood illnesses specified by the department in accordance with recommendations of Immunization Practices Advisory Committee (ACIP). The parent or guardian of the child shall provide satisfactory evidence of the required immunizations. Satisfactory evidence means a statement, certificate or record from a physician or other recognized health facility or personnel, stating that the required immunizations have been given to the child and verifying the type of vaccine and the month, day and year of administration.
Correction Required
Child immunization requirements shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

19 CSR 30-61.190 Nutrition and Food Service
Compliance
19 CSR 30-61.200 Transportation and Field Trips
Compliance
19 CSR 30-61.210 Records and Reports
Violation
 Provider Comments
Violation
1 child(ren) records did not include child's full name, address, date of birth and date care begins and ends.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (A) states: The child’s full name, address, birth date and the date care begins and ends.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include full name, home address, employers name and address, work schedule and home and work telephone numbers of the parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include name, address and telephone number of another individual who might be reached in an emergency.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (C) states: Name, address and telephone number of another individual (friend or relative) who might be reached in an emergency when the parent(s), guardian or legal custodian cannot be reached.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include telephone number of family physician or hospital.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (D) states: Name and phone number of the family physician, or hospital, or both, to be used in an emergency.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include name of individual authorized to take the child from the home.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (E) states: Name of the individual(s) authorized to take the child from the home.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include field trip and transportation authorization.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (F) states: Field trip and transportation authorization.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include name and phone number of the family physician or hospital.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (D) states: Name and phone number of the family physician, or hospital, or both, to be used in an emergency.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include name of family physician or hospital.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (D) states: Name and phone number of the family physician, or hospital, or both, to be used in an emergency.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include work telephone number of parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include home telephone number of parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include work schedule of parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include home address of parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include full name of parent(s), guardian or legal custodian.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers’ name and address, work schedule and home and work telephone numbers.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include date care begins and ends.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (A) states: The child’s full name, address, birth date and the date care begins and ends.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include child's birth date.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (A) states: The child’s full name, address, birth date and the date care begins and ends.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include child's address.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (A) states: The child’s full name, address, birth date and the date care begins and ends.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include child's full name.
Licensing Rule Reference
19 CSR 30-61.210 Records and Reports (2) (A) states: The child’s full name, address, birth date and the date care begins and ends.
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

19 CSR 30-63.020 General Requirements
Compliance
19 CSR 30-63.040 Background Screening Findings
Compliance
RSMo 210.115. Reports of abuse, neglect, and under age eighteen deaths - persons required to report - supervisors and administrators not to impede reporting - deaths required to be reported to the division or child fatality review panel, when - report made to another state, when.
Compliance
RSMo 210.211.  License required - exceptions - written notice of licensure status, when.
Compliance
RSMo 210.252. Fire, safety, health and sanitation inspections, procedures - variances to rules granted when - rules authorized.
Compliance