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

SUSAN MARIE DOUGLAS

5 YEARS - 13 YEARS

96

SCHOOL AGE

 
Inspection Information

04/28/2022

2:40 PM

4:27 PM

UNANNOUNCED

COMPLIANCE MONITORING

2422696631


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
ANNUAL DECLARATION 11/19/2020
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 11/19/2020
EQUIPMENT LIST 11/19/2020




Inspection determined facility to be in compliance with licensing rules.
Open Violations: 4
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 5
Total Children 39
StaffChildClass AgeNote
5 39 SCHOOL AGE Jane Bell, staff, Olivia Hutt staff, Tyler Pedersen staff, Loretta Woodward ,staff, Noveta Shephard, program director were present with 39 children ages 5 to 11

 
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
Violation
 Provider Comments
Violation
Requirements of the facility's participation in disaster and emergency drills were not met as evidenced by the disaster or emergency drill was not held at least one time every three months.
Licensing Rule Reference
5 CSR 25-500.090 Disaster and Emergency Preparedness (3) (A) states: The licensee shall ensure that the facility has on file documentation that, at least every three (3) months, all staff and children at the facility have participated in a disaster or emergency drill based on the facility's disaster and emergency plan.
Correction Required
Fire, tornado, and other disaster drills shall be completed and recorded as required.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.092 Furniture, Equipment and Materials
Compliance
5 CSR 25-500.102 Personnel
Violation
 Provider Comments
Violation
A facility orientation was not documented and available for review for all caregivers. The following staff need documentation of a facility orientation: Jane Bell, Jeremy Booth, Olivia Hutt, Cindy Martin, Tyler Pederson.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (1) (K) . states: The child care provider shall ensure that within seven (7) days of employment or volunteering and before being left alone with children that caregivers receive a facility orientation. The child care provider shall ensure that documentation verifying completion of the facility orientation is maintained and on file for review by the department for each caregiver. The facility orientation shall include:
Correction Required
The facility shall ensure that a facility orientation occurs within 7 days and documentation verifying completion is maintained and on file for review by the department for each caregiver.

Correction Verification
Submit Documentation

Compliance Date

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
An individualized plan for specialized care for a child with special physical, developmental or behavioral needs was not on file.
Licensing Rule Reference
5 CSR 25-500.132 Admission Policies and Procedures (6) states: A child who has a special physical, developmental or behavioral need shall have on file an individualized plan for specialized care from a professionally qualified source.
Correction Required
An individualized plan from a professional source shall be on file as required.

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
Violation
 Provider Comments
Violation
1 child(ren) records did not include employers' address of parent(s), guardian or legal custodian.
Licensing Rule Reference
5 CSR 25-500.222 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

5 CSR 25-600.020 General Requirements
Compliance
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