DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

GROUP HOME AND CENTER INSPECTION REPORT
Facility Information

DUNCAN ACADEMY, INC.

001913568

(816) 847-2022

1405 NW PERSIMMON
GRAIN VALLEY
MO  64029

DUNCAN ACADEMY, INC.



 

GILLETTE, ALISON

ali@duncanacademy.com


BIONICA D SMITHJACKSON

6 WEEKS - 12 YEARS

145

GROUP HOME AND CENTER

29 CHILDREN IN THE INFANT/TODDLER UNIT; 12 CHILDREN UNDER 12 MONTHS; 116 FULL DAY PRESCHOOL CHILDREN
 
Inspection Information

06/20/2023

9:15 AM

10:25 AM

UNANNOUNCED

REINSPECTION

2449321413


DocumentDocument-Date
SAMPLE WEEKLY MENU 07/18/2005
SAMPLE FORMS 07/18/2005
POLICIES 07/18/2005
LOCAL ZONING APPROVAL 07/21/2005
LOCAL BUILDING APPROVAL 07/21/2005
LINES OF ADMINISTRATIVE AUTHORITY 07/18/2005
DIRECTOR'S QUALIFICATIONS 07/18/2005
DIAGRAM/OUTDOOR 07/22/2005
DIAGRAM/INDOOR 07/22/2005
DAILY SCHEDULE 07/18/2005
CHILD CARE PRACTICES 07/18/2005
ARTICLES OF INCORPORATION 09/07/2004
DISCIPLINE POLICIES 07/18/2005
JOB RESPONSIBILITIES 07/18/2005
REGISTERING FICTITIOUS NAMES 04/05/2015
SAFE SLEEP POLICY 04/11/2018
APPLICATION 04/10/2019
CERTIFICATE OF GOOD STANDING 06/14/2023
DISASTER AND EMERGENCY PREPAREDNESS PLAN 04/10/2019
EQUIPMENT LIST 06/14/2023
STAFF SHEET 05/01/2021
SANITATION INSPECTION 03/13/2023
FIRE/SAFETY INSPECTION 06/06/2022
ANNUAL DECLARATION 06/06/2022
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 06/14/2023




Inspection determined facility to be in compliance with licensing rules.
Open Violations: 23
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 16
Total Children 79
StaffChildClass AgeNote
2 6 INFANTS AND TODDLERS caregivers Nicole Crawford and Courtney McPheron six children under 12 months
2 8 INFANTS AND TODDLERS caregivers Krystal Harper and Megan Brewer with eight children under 24 months
2 7 INFANTS AND TODDLERS caregivers Alyssa Caldwell and Gabrielle Cooper with seven children 12 months old
3 0 NO CHILDREN IN ATTENDANCE director Alison Gillette and staff Ashley Benny and Jessica Brockman with no children
2 18 PRESCHOOL caregivers Shonda Hicks and Katey Bedard with eighteen children, all 3-to-4-years-old
1 8 PRESCHOOL caregiver Kristen Ferman with eight children, all 3-years-old
1 8 PRESCHOOL caregiver Jennifer Meyers with eight children, all 3-years-old
1 14 SCHOOL AGE caregiver Kensey Lamb with fourteen school-age children
2 10 TWO YEAR OLDS caregivers Paige McPheron and Yvette Burr with ten children, all 2-years-old

 
5 CSR 25-500.032 Organization and Administration
Not Observed
5 CSR 25-500.042 Licensing Process
Not Observed
5 CSR 25-500.052 Annual Requirements
Violation
 Provider Comments
Violation
The annual fire safety inspection was not conducted.
Licensing Rule Reference
5 CSR 25-500.052 Annual Requirements (2) (A) states: Evidence of compliance with a fire and safety inspection as conducted by the State Fire Marshal or his/her designee.
Correction Required
The facility shall submit evidence of compliance with annual fire safety requirements.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers
Violation
 Provider Comments
Violation
The walls located hallway (storage door), dragonflies #2, ladybugs, dragonflies #1 was/were not in good condition as evidenced by exposed wood, holes and chipping paint, sticky residue on doors.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (2) (A) 6. states: Walls, ceilings and floors shall be finished with material which can be cleaned easily and shall be free of splinters, cracks and chipping paint. Floor covering shall be in good condition. Lead-free paint shall be used for all painted surfaces.
Correction Required
Walls, ceilings, and floors shall be made of approved materials, easily cleaned and in good condition.

Correction Verification
Submit Documentation

Compliance Date

Violation
The floors located school-age, dragonflies #1 &2, ladybugs #1&2, was/were not clean as evidenced by sticky residue/tape and stained carpets.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (2) (A) 6. states: Walls, ceilings and floors shall be finished with material which can be cleaned easily and shall be free of splinters, cracks and chipping paint. Floor covering shall be in good condition. Lead-free paint shall be used for all painted surfaces.
Correction Required
Walls, ceilings, and floors shall be made of approved materials, easily cleaned and in good condition.

Correction Verification
Submit Documentation

Compliance Date

Violation
The ceilings located throughout the center was/were not clean as evidenced by dusty returns and light covers.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (2) (A) 6. states: Walls, ceilings and floors shall be finished with material which can be cleaned easily and shall be free of splinters, cracks and chipping paint. Floor covering shall be in good condition. Lead-free paint shall be used for all painted surfaces.
Correction Required
Walls, ceilings, and floors shall be made of approved materials, easily cleaned and in good condition.

Correction Verification
Submit Documentation

Compliance Date
6/20/2023
Violation
The concrete floors located Monkeys #1 and boys bathroom was/were not covered with approved materials as evidenced by pieces of floor tiles missing.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (2) (A) 7. states: Concrete floors in areas counted as child care space shall be covered with carpet, tile, linoleum or other floor covering.
Correction Required
Floors shall be made of approved materials.

Correction Verification
Submit Documentation

Compliance Date

Violation
The facility did not have a fenced outdoor play area that was on or adjoining the day care property and was accessible without hazard as evidenced by the fence had openings that were between 3.5 and 9 inches and allow entrapment - the openings measured 3.5-8 inches.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (6) (A) 1. states: A fenced outdoor play area shall be available on or adjoining the day care property. The play area shall be located so it is convenient and the children can gain access to it without hazard. For facilities initially licensed after the effective date of these rules or for the installation of new fences in existing facilities, the fence shall be at least forty-two inches (42") high. An outdoor play area used exclusively for school-age children shall not be required to have a fence. Fences shall be constructed to prevent children from crawling or falling through or becoming entrapped.
Correction Required
The outdoor play area shall be accessible without hazard.

Correction Verification
Submit Documentation

Compliance Date

Violation
The facility's outdoor space was not safe for children's activities as evidenced by plastic timber piece broken.
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

Violation
The fall-zone area under and around outdoor equipment where children might fall and be injured was not covered with impact-absorbing materials to cushion a fall as evidenced by resilient material was not uniformly spread over the fall-zone area.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (6) (A) 7. states: Areas under and around outdoor equipment shall have continuous maintenance to ensure that the material remains in place and retains its cushioning properties. The resilient material shall be supplemented immediately or replaced as needed.
Correction Required
The facility shall maintain approved resilient material in all fall-zone areas.

Correction Verification
Submit Documentation

Compliance Date

Violation
The requirements for toilet and handwashing facilities were not met as evidenced by the toilet was not convenient for children's use.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (3) (A) 3. states: Toilet and hand washing facilities shall be in working order and convenient for the children's use.
Correction Required
Bathroom fixtures shall be functional and convenient.

Correction Verification
Submit Documentation

Compliance Date

Violation
The wading pool used by children was not properly used as evidenced by pool was in front of building near the parking lot.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (7) (A) states: Swimming and wading pools used by children shall be constructed, maintained and used in a manner which safeguards the lives and health of children.
Correction Required
Swimming and wading pools used by children shall be constructed, maintained and used in a manner which safeguards the lives and health of children as required.

Correction Verification
Submit Documentation

Compliance Date
6/20/2023
5 CSR 25-500.087 Fire Safety
Not Observed
5 CSR 25-500.090 Disaster and Emergency Preparedness
Not Observed
5 CSR 25-500.092 Furniture, Equipment and Materials
Violation
 Provider Comments
Violation
Furniture/equipment, step stools, counter and chairs, in boys bathroom and Bumblebees, dragonflies #1, was not in good condition as evidenced by overly soiled, chipped counter top, and rust on chair legs.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (1) (A) 1. states: All furniture and equipment shall be constructed safely, in good condition and free of sharp, loose or pointed parts. Only lead-free paint shall be used.
Correction Required
The facility shall provide safe and clean furniture/equipment as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
Furniture/equipment, shelves, bench, in in school-age room, toddler rooms, Monkeys #1, dragonflies #2 was not in good condition as evidenced by chipping paint, exposed wood and sticky residue.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (1) (A) 1. states: All furniture and equipment shall be constructed safely, in good condition and free of sharp, loose or pointed parts. Only lead-free paint shall be used.
Correction Required
The facility shall provide safe and clean furniture/equipment as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
Stationary equipment, rock climbing wall, was unsafe as evidenced by the equipment had exposed footings.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (3) (D) states: Stationary equipment such as swings, slides and climbers shall be securely anchored, have no exposed footings and be placed to avoid accidents or collisions.
Correction Required
Stationary equipment shall be safely installed, stable and securely anchored.

Correction Verification
Submit Documentation

Compliance Date

Violation
Outdoor equipment, play kitchen, in toddler playground was not in good condition as evidenced by piece torn off.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (3) (A) states: All outdoor equipment shall be constructed safely, in good condition and free of sharp, loose or pointed parts. Only lead-free paint shall be used.
Correction Required
Outdoor play equipment shall be safe and in good repair.

Correction Verification
Submit Documentation

Compliance Date

Violation
Outdoor equipment, playhouse, in preschool playground was unsafe as evidenced by hole in the floor.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (3) (A) states: All outdoor equipment shall be constructed safely, in good condition and free of sharp, loose or pointed parts. Only lead-free paint shall be used.
Correction Required
Outdoor play equipment shall be safe and in good repair.

Correction Verification
Submit Documentation

Compliance Date

Violation
Outdoor equipment, large playground equipment, in preschool playground was not in good condition as evidenced by rusting, covering peeling off, and broken pieces.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (3) (A) states: All outdoor equipment shall be constructed safely, in good condition and free of sharp, loose or pointed parts. Only lead-free paint shall be used.
Correction Required
Outdoor play equipment shall be safe and in good repair.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.102 Personnel
Violation
 Provider Comments
Violation
Shonda Hicks did not complete safe sleep training within 30 days of employment or volunteering at the facility.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (4) (A) 3. states: The child care provider, group child care home provider, child care staff members, and volunteers shall complete safe sleep training described in subsection (4)(A) of this rule within thirty (30) days of employment or volunteering at the facility.
Correction Required
The department-approved safe sleep training must be completed within 30 days of employment or volunteering.

Correction Verification
Submit Documentation

Compliance Date

Violation
Documentation of caregiver completion of the facility orientation was not on file for the following staff: Chloe Bailey, Megan Brewer, Cooper Deickhoff, Lily Gonzolez, Emma Kratz, Virginia Neace Kensey Lamb,.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (1) (L) states: The child care provider shall ensure that documentation of caregiver completion of the facility orientation is maintained and on file for review by the department.
Correction Required
Documentation of caregiver completion of the facility orientation shall be maintained and on file for review by the department as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
Background screening information was not kept confidential for Kaitlyn Bedard, Alyssa Caldwell, Gabrielle Cooper, Jennifer Giles, Lily Gonzolez, Jessica Herman, Jennifer Herrera, Emma Kratz, Paige McPheron, Virginia Neace, Donna Thompson, Nicole Love .
Licensing Rule Reference
5 CSR 25-500.102 Personnel (1) (Q) states: Background screening information received by the provider shall be retained in the individual’s file in a confidential manner and available for review.
Correction Required
Background screening information shall be kept confidential.

Correction Verification
Submit Documentation

Compliance Date

Violation
A caregiver did not obtain one clock hour of training for each month of employment. The staff listed need the following information: McKenna Ferman-needs 1 hour.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (3) (C) states: Caregivers who were employed after the first of the year shall obtain one (1) clock of hour training for each one (1) month of employment, regardless of the date employment began.
Correction Required
Required training hours shall be documented for each employee.

Correction Verification
Submit Documentation

Compliance Date
6/20/2023
Violation
The requirements for obtaining 12 clock hours each calendar year were not met. For the calendar year of 2022, the staff listed need the following information: Virginia Neace-needs 2 hours.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (3) (A) states: The center director, group child care home provider, all other caregivers, and those volunteers who are counted in staff/child ratios shall obtain at least twelve (12) clock hours of child-care related training during each calendar year. Clock hour training shall be approved by the department.
Correction Required
Required training hours shall be documented for each caregiver.

Correction Verification
Submit Documentation

Compliance Date

Violation
The requirements for obtaining 12 clock hours each calendar year were not met. For the calendar year of 2022, the staff listed need the following information: Cooper Deickhoff-needs 2 hours; Lily Gonzolez-needs 2 hours; Krystal Harper-needs 6.5 hours.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (3) (A) states: The center director, group child care home provider, all other caregivers, and those volunteers who are counted in staff/child ratios shall obtain at least twelve (12) clock hours of child-care related training during each calendar year. Clock hour training shall be approved by the department.
Correction Required
Required training hours shall be documented 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
Violation
 Provider Comments
Violation
Medical examination report(s) was/were not on file for Cooper Deickhoff, Makenna Ferman, Kristen Ferman, Shaniah Cope, Jennifer Herrera, Kensey Lamb, Paige McPheron, Courtney McPheron, Donna Thompson as evidenced by a medical examination was not on file within 30 days of an individual beginning to work with children.
Licensing Rule Reference
5 CSR 25-500.122 Medical Examination Reports (1) (A) states: All persons working in a child care facility in any capacity during child care hours, including volunteers counted in staff/child ratios, shall be in good physical and emotional health with no physical or mental conditions which would interfere with child care responsibilities. These persons shall have a medical examination report, signed by a licensed physician or registered nurse who is under the supervision of a licensed physician, on file at the facility at the time of initial licensure or within thirty (30) days following employment.
Correction Required
Medical reports shall be on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
A medical examination report included either a Risk Assessment for Tuberculosis form or a negative tuberculin skin test (TST) which was completed more than 12 months before beginning work in the facility for the following staff: Megan Brewer, Yvette Burr, Kristen Ferman, Courtney McPheron, Donna Thompson, Shonda Hicks.
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 tuberculin skin test (TST) as required.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.132 Admission Policies and Procedures
Not Observed
5 CSR 25-500.142 Nighttime Care
Not Observed
5 CSR 25-500.162 Overlap Care of Children
Not Observed
5 CSR 25-500.172 Emergency School Closings
Not Observed
5 CSR 25-500.182 Child Care Program
Not Observed
5 CSR 25-500.192 Health Care
Not Observed
5 CSR 25-500.202 Nutrition and Food Service
Violation
 Provider Comments
Violation
The provider did not meet requirements for a written diet plan for each infant and toddler as evidenced by the written diet plan was not updated for a child in that no toddler feeding plan on file.
Licensing Rule Reference
5 CSR 25-500.202 Nutrition and Food Service (2) (B) states: The written diet plan for each infant/toddler shall be followed. The parent(s) shall update the plan according to the individual needs of the child until they grant permission in writing for the child to eat table foods.
Correction Required
A written diet plan shall be on file for each infant/toddler, updated as needed and followed by caregivers.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.212 Transportation and Field Trips
Not Observed
5 CSR 25-500.222 Records and Reports
Not Observed
5 CSR 25-600.020 General Requirements
Violation
 Provider Comments
Violation
Criminal background check results were not on file for Chloe Bailey, Megan Brewer, Cooper Deickhoff, Shaniah Cope, Makenna Ferman, Kristen Ferman, Kensey Lamb, Courtney McPheron, Teran Potter, Kira Potter, Madison Montgomery, Shonda Hicks.
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 licensed, regulated, or registered child care 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
Not Observed
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. —
Not Observed
RSMo 210.211.  License required - exceptions - written notice of licensure status, when.
Not Observed