DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

GROUP HOME AND CENTER INSPECTION REPORT
Facility Information

HERMITAGE R-IV SCHOOL DISTRICT

001581999

(417) 745-2133

23824 POLK ST
HERMITAGE
MO  65668-8213

HERMITAGE R-IV SCHOOL DISTRICT

PO BOX 327
HERMITAGE
MO  65668

WHITNEY, MONICA

mgcarter10@yahoo.com


LACEY BERENDZEN

36 MONTHS - 5 YEARS

15

GROUP HOME AND CENTER

 
Inspection Information

10/27/2022

N/A

N/A

N/A

COMPLIANCE VERIFICATION

2434229466


DocumentDocument-Date
SAMPLE WEEKLY MENU 05/25/2004
SAMPLE FORMS 11/15/2004
POLICIES 06/24/2009
LINES OF ADMINISTRATIVE AUTHORITY 11/15/2004
JOB RESPONSIBILITIES 06/24/2009
DISCIPLINE POLICIES 06/24/2009
CHILD CARE PRACTICES 02/18/2005
REGISTERING FICTITIOUS NAMES 08/19/2010
DIRECTOR'S QUALIFICATIONS 03/31/2014
APPLICATION 06/03/2019
STAFF SHEET 08/23/2021
DIAGRAM/OUTDOOR 07/11/2021
DIAGRAM/INDOOR 07/11/2021
DAILY SCHEDULE 08/23/2021
SANITATION INSPECTION 09/27/2022
FIRE/SAFETY INSPECTION 07/26/2022
ANNUAL DECLARATION 08/01/2022
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 08/01/2022
DISASTER AND EMERGENCY PREPAREDNESS PLAN 08/23/2021
LOCAL FIRE DEPARTMENT NOTIFICATION 08/23/2021
EQUIPMENT LIST 08/01/2022
LOCAL ZONING APPROVAL 09/29/2021
LOCAL BUILDING APPROVAL 09/29/2021




Inspection determined facility to be in compliance with licensing rules.
Open Violations: NA
NOTE
The licensee is responsible for compliance with all licensing rules, including but not limited to the rules listed on this compliance report form.

 
5 CSR 25-500.032 Organization and Administration
Compliance
5 CSR 25-500.042 Licensing Process
Compliance
5 CSR 25-500.052 Annual Requirements
Violation
 Provider Comments
Violation
The annual sanitation inspection was not conducted.
Licensing Rule Reference
5 CSR 25-500.052 Annual Requirements (2) (B) states: Evidence of compliance with local, state, or both, sanitation requirements.
Correction Required
The facility shall submit evidence of compliance with annual sanitation requirements.

Correction Verification
Submit Documentation

Compliance Date
9/27/2022
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers
Violation
 Provider Comments
Violation
The facility's outdoor space was not safe for children's activities as evidenced by the trim is broken and sharp on the door frame that leads underneath the building and has chipping paint.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (6) (A) 4. states: The play area shall be safe for children's activities, well-maintained, free of hazards such as poisonous plants, broken glass, rocks or other debris and shall have good drainage.
Correction Required
The outdoor play area shall be clean, safe and well-maintained as required.

Correction Verification
Submit Documentation

Compliance Date
9/23/2022
5 CSR 25-500.087 Fire Safety
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
Violation
 Provider Comments
Violation
A medical examination report did not include either a Risk Assessment for Tuberculosis form or a negative tuberculin skin test (TST for the following staff: Monica Whitney.
Licensing Rule Reference
5 CSR 25-500.122 Medical Examination Reports (1) (B) . states: Medical examination reports shall include either a Tuberculosis (TB) Risk Assessment form, completed and signed by a health care professional, or a negative tuberculin skin test (TST) completed not more than twelve (12) months before beginning work in the facility. The Tuberculosis (TB) Risk Assessment form, revised March 2014, is incorporated by reference in this rule, as published by the Missouri Department of Health and Senior Services, PO Box 570, Jefferson City, MO 65102 and available by the Missouri Department of Health and Senior Services at https://health.mo.gov/living/healthcondiseases/communicable/tuberculosis/tbmanual/pdf/RiskAssessmentform.pdf. If the person has signs or symptoms of tuberculosis, or risk factors for tuberculosis, then testing for tuberculosis shall occur.
Correction Required
Medical examination reports shall include Risk Assessment for Tuberculosis forms or negative tuberulin skin test (TST) as required.

Correction Verification
Submit Documentation

Compliance Date
10/26/2022
5 CSR 25-500.132 Admission Policies and Procedures
Compliance
5 CSR 25-500.142 Nighttime Care
Compliance
5 CSR 25-500.162 Overlap Care of Children
Compliance
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 name, address and telephone number of another individual who might be reached in an emergency.
Licensing Rule Reference
5 CSR 25-500.222 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
10/26/2022
Violation
1 child(ren) records did not include telephone number of family physician or hospital.
Licensing Rule Reference
5 CSR 25-500.222 Records and Reports (2) (D) states: Name and phone number of the family physician, 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
10/26/2022
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