DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

SCHOOL AGE INSPECTION REPORT
Facility Information

TWIN PIKE FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.

001779428

(573) 754-6904

500 HALEY AVE
LOUISIANA
MO  63353-2417

TWIN PIKE FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.

614 KELLY LN
LOUISIANA
MO  63353-2409

PEDERSEN, TERESA LEE

Noveta.Shepherd@twinpikefamilyymca.org

Incorporated

JOY LYNN NICHOLS

5 YEARS - 13 YEARS

96

SCHOOL AGE

 
Inspection Information

11/09/2021

4:25 PM

5:41 PM

UNANNOUNCED

COMPLIANCE MONITORING

2412242011


DocumentDocument-Date
SAMPLE FORMS 09/05/2003
LINES OF ADMINISTRATIVE AUTHORITY 08/27/2007
POLICIES 09/05/2003
SAMPLE WEEKLY MENU 09/05/2003
DAILY SCHEDULE 06/01/2004
CERTIFICATE OF GOOD STANDING 09/24/2013
DIRECTOR'S QUALIFICATIONS 09/24/2013
APPLICATION 08/22/2019
STAFF SHEET 09/19/2019
CHILD CARE PRACTICES 07/10/2003
DISCIPLINE POLICIES 09/05/2003
DIRECTOR'S JOB RESPONSIBILITIES 09/20/2005
ARTICLES OF INCORPORATION 10/29/2002
LOCAL FIRE DEPARTMENT NOTIFICATION 10/29/2003
JOB RESPONSIBILITIES 07/10/2003
CERTIFICATE OF INCORPORATION 10/29/2003
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 09/27/2021
EQUIPMENT LIST 09/27/2021
ANNUAL DECLARATION 09/27/2021




Inspection determined facility to be in compliance with licensing rules.
Open Violations: 2
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 4
Total Children 19
StaffChildClass AgeNote
1 1 SCHOOL AGE 1 child age nine; Teresa Pedersen
3 18 SCHOOL AGE children ages five to ten; Robin Ozelius, Tyler Pedersen, and Olivia Hutt

 
5 CSR 25-500.032 Organization and Administration
Compliance
5 CSR 25-500.042 Licensing Process
Compliance
5 CSR 25-500.052 Annual Requirements
Compliance
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers
Compliance
5 CSR 25-500.090 Disaster and Emergency Preparedness
Compliance
5 CSR 25-500.092 Furniture, Equipment and Materials
Compliance
5 CSR 25-500.102 Personnel
Compliance
5 CSR 25-500.112 Staff/Child Ratios
Compliance
5 CSR 25-500.122 Medical Examination Reports
Compliance
5 CSR 25-500.132 Admission Policies and Procedures
Violation
 Provider Comments
Violation
The facility did not meet requirements for child enrollment and health information on file as evidenced by child(s) file(s) did not have the parental acknowledgement they have been notified that they may request whether there are children for whom an immunization exemption has been filed for currently enrolled in or attending the facility.
Licensing Rule Reference
5 CSR 25-500.132 Admission Policies and Procedures (8) (E) 8. F. states: They have been notified that they may request notice at initial enrollment in or attendance at the facility or upon request of whether there are children for whom an immunization exemption has been filed currently enrolled in or attending the facility.
Correction Required
Child enrollment information shall be completed and on file as requested.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.172 Emergency School Closings
Compliance
5 CSR 25-500.182 Child Care Program
Compliance
5 CSR 25-500.192 Health Care
Compliance
5 CSR 25-500.202 Nutrition and Food Service
Compliance
5 CSR 25-500.212 Transportation and Field Trips
Compliance
5 CSR 25-500.222 Records and Reports
Compliance
5 CSR 25-600.020 General Requirements
Violation
 Provider Comments
Violation
Criminal background check results were not on file for Loretta Woodward.
Licensing Rule Reference
5 CSR 25-600.020 General Requirements (1) states: Prior to the employment or presence of a child care staff member in a family child care home, group child care home, child care center, or license-exempt facility not exempted by section 210.1080.13, RSMo, the child care provider shall request the results of a criminal background check for such child care staff member from the department.
Correction Required
Required results of criminal background checks shall be on file.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-600.040 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