DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

GROUP HOME AND CENTER INSPECTION REPORT
Facility Information

HOLY CROSS LUTHERAN CHURCH OF KANSAS CITY

000186383

(816) 452-9113

2003 NE ENGLEWOOD RD
KANSAS CITY
MO  64118

HOLY CROSS LUTHERAN CHURCH OF KANSAS CITY



 

PURL, CHRISTINE DAWN

ecc@holycrosskc.org

Incorporated

BIONICA D SMITHJACKSON

6 WEEKS - 12 YEARS

99

GROUP HOME AND CENTER

24 CHILDREN IN THE INFANT/TODDLER UNIT; 8 CHILDREN UNDER 12 MONTHS; 24 CHILDREN UNDER 24 MONTHS
 
Inspection Information

07/05/2023

11:18 AM

1:35 PM

UNANNOUNCED

COMPLIANCE MONITORING

2450115223


DocumentDocument-Date
POLICIES 06/17/1985
LOCAL ZONING APPROVAL 10/21/1991
LOCAL BUILDING APPROVAL 10/21/1991
LINES OF ADMINISTRATIVE AUTHORITY 06/28/1993
JOB RESPONSIBILITIES 06/28/1993
DIRECTOR'S QUALIFICATIONS 06/19/2007
DIAGRAM/OUTDOOR 09/20/2010
DIAGRAM/INDOOR 01/19/2010
DAILY SCHEDULE 06/17/1985
DISASTER AND EMERGENCY PREPAREDNESS PLAN 05/01/2018
SAFE SLEEP POLICY 05/01/2018
SAMPLE FORMS 06/05/1985
APPLICATION 03/04/2019
STAFF SHEET 05/06/2019
SAMPLE WEEKLY MENU 05/06/2019
CHILD CARE PRACTICES 07/12/2021
DISCIPLINE POLICIES 07/12/2021
ANNUAL DECLARATION 06/08/2023
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 06/13/2022
EQUIPMENT LIST 06/08/2023
FIRE/SAFETY INSPECTION 04/13/2022
CERTIFICATE OF GOOD STANDING 06/08/2023
SANITATION INSPECTION 04/05/2023




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 17
Total Children 36
StaffChildClass AgeNote
3 5 INFANTS AND TODDLERS caregivers Alesia Kendall, Emma Williams, and Carol Wilson with five children under 12-months
1 2 INFANTS AND TODDLERS caregiver Alexandria Espino with two children 12-months and under
2 5 INFANTS AND TODDLERS caregivers Rebecca Ohlde and Tracy Watson with five children under 24-months
5 24 MIXED caregivers Jessica Begley, Catie Purl, Kim Mcoy, Patti Mael, and Sandy Ledford with twenty-four children, seven 2-years-old and seventeen 3-to-5-years-old
6 0 NO CHILDREN IN ATTENDANCE staff Staci Williams, Brandi Schauman, Josephine Biggs, Carl Pigors, Shara Pigors, and Randall Wilson

 
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 Family Care Safety Registry check was not conducted for Kim McCoy, Christine Purl, Carol Wilson, Randall Wilson, within thirty (30) days prior to the anniversary date.
Licensing Rule Reference
5 CSR 25-500.052 Annual Requirements (2) (C) states: The child care provider shall conduct a Family Care Safety Registry check for all child care staff members within thirty (30) days prior to the anniversary date as printed on the license.
Correction Required
Required Family Care Safety Registry checks shall be conducted for all child care staff member(s) within thirty (30) days prior to the anniversary date.

Correction Verification
Submit Documentation

Compliance Date

Violation
The annual fire safety inspection was not approved.
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

Violation
The staff sheet was not fully completed as evidenced by missing signature.
Licensing Rule Reference
5 CSR 25-500.052 Annual Requirements (1) (D) states: A current staff sheet.
Correction Required
The facility shall submit a current staff sheet as required.

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
Hazardous items as follows were accessible to children: knife . The item(s) was/were located unlocked drawer.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (1) (I) states: All flammable liquids, matches, cleaning supplies, poisonous materials, medicines, alcoholic beverages, hazardous personal care items or other hazardous items shall be inaccessible to children.
Correction Required
Hazardous items shall be inaccessible to children.

Correction Verification
Corrected on Site

Compliance Date
7/5/2023
Violation
The ceilings located infant room was/were not in good condition as evidenced by vent cover missing.
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
Diapering requirements were not met as evidenced by the diapering table did not have a waterproof washable surface.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (4) (A) states: A safe diapering table with a waterproof washable surface shall be used for changing diapers. The diapering table shall be located within or adjacent to the group space so the caregiver using the diapering table can maintain supervision of his/her group of children at all times.
Correction Required
The facility shall provide a safe and clean diapering table as required.

Correction Verification
Corrected on Site

Compliance Date
7/5/2023
Violation
The bathroom was not clean and odor free as evidenced by the floor was soiled.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (3) (A) 7. states: Bathrooms shall be clean and odor free.
Correction Required
Bathrooms shall be clean and odor free.

Correction Verification
Submit Documentation

Compliance Date

Violation
Animal excrement was observed in an indoor area used by children; the location of the excrement was in hallway; cages accessible to children.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (8) (E) states: Areas used by children shall be free of animal excrement.
Correction Required
No animal excrement shall be in areas used by children.

Correction Verification
Submit Documentation

Compliance Date

Violation
The bathroom was not clean and odor free as evidenced by the wall was soiled.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (3) (A) 7. states: Bathrooms shall be clean and odor free.
Correction Required
Bathrooms shall be clean and odor free.

Correction Verification
Submit Documentation

Compliance Date

Violation
The walls located in crusaders room, preschool room, was/were not clean as evidenced by sticky residue on chalk board walls, dusty window frame.
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 in toddler room and whales room was/were not clean as evidenced by dirty mats and tape peeling off floors.
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 in crusaders and eagles was/were not clean as evidenced by debris in corners and window sill dirty.
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
Children were not restricted to approved space as evidenced by staff rooms and mechanical room not closed/locked.
Licensing Rule Reference
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers (1) (C) states: Children shall have no access to areas not approved for child care.
Correction Required
Caregivers shall restrict children to approved space.

Correction Verification
Corrected on Site

Compliance Date
7/5/2023
Violation
The walls located in eagles room and hallway was/were not in good condition as evidenced by paint chipping on poles and wood wearing on door.
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

5 CSR 25-500.087 Fire Safety
Compliance
5 CSR 25-500.090 Disaster and Emergency Preparedness
Violation
 Provider Comments
Violation
Requirements of facilities 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
Violation
 Provider Comments
Violation
Furniture/equipment, shelves, cabinets, trash can, toy kitchen, in crusaders, whales, and lions rooms was not in good condition as evidenced by sticky residue and contact paper peeling, dirty, broken trash can, dust in crevices of kitchen.
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
Outdoor equipment, toy boat, in toddler playground was not in good condition as evidenced by broken.
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
Furniture/equipment, changing tables, in toddler room and whales rooms was not in good condition as evidenced by 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

5 CSR 25-500.102 Personnel
Violation
 Provider Comments
Violation
Safe sleep training was not completed within the past 3 years for the following staff Rebecca Ohlde.
Licensing Rule Reference
5 CSR 25-500.102 Personnel (4) (A) . states: Every three (3) years, the child care provider, group child care home provider, child care staff members, and volunteers in a group child care home or child care center licensed to provide care for infants less than one (1) year of age shall successfully complete department-approved training regarding the American Academy of Pediatrics (AAP) safe sleep recommendations contained in the American Academy of Pediatrics Policy Statement on sleep-related infant deaths. The Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment, July 2022, is incorporated by reference in this rule, as published by the American Academy of Pediatrics and available at https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022 or as published in PEDIATRICS Volume 150, Issue 1, July 2022. A copy can also be obtained from the Department of Elementary and Secondary Education, Office of Childhood, 205 Jefferson Street, PO Box 480, Jefferson City, MO 65102-0480 and at https://dese.mo.gov/governmental-affairs/deseadministrativerules/incorporated-reference-materials. This rule does not incorporate any subsequent amendments or additions.
Correction Required
The director, group home provider, other caregivers, and those volunteers counted in staff/child ratio, shall complete department-approved safe sleep training as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
Jessica Begley, Josie Biggs, Meagan Barnett, Brooklyn Glassbrenner 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
A facility orientation was not conducted for a caregiver(s) before being left alone with children. The following staff need a facility orientation: Jessica Begley, Josie Barnett, Brooklyn Glassbrenner, Tracy Watson, Emma Wilson
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 employed on or after August 30, 2019, receive a facility orientation. The facility orientation shall include:
Correction Required
The facility shall ensure that a facility orientation occurs within 7 days of employment or volunteering and before caregivers are left alone with children.

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
Requirements for infant-toddler/preschool child medical examination reports on file were not met as evidenced by there was no medical examination report on file within 30 days of admission - the admission date(s) was/were 11/15/2021.
Licensing Rule Reference
5 CSR 25-500.122 Medical Examination Reports (2) (A) states: The provider, within thirty (30) days following the admission of each infant, toddler or preschool child, shall require a medical examination report signed by a licensed physician or registered nurse who is under the supervision of a licensed physician and completed not more than twelve (12) months prior to admission. The provider may use the department’s medical assessment form or the provider may use its own form if it contains all the information on the department’s form. The Child Medical Examination Report (Infant/Toddler/Pre-School)form, revised 2021, is incorporated by reference in this rule, as published by the Missouri Department of Elementary and Secondary Education, PO Box 480, Jefferson City, MO 65102-0480 and available by the department at https://dese.mo.gov/childhood/forms. This rule does not incorporate any subsequent amendments or additions.
Correction Required
Child medical requirements shall be completed and 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: Meagan Barnett, Brooklyn Glassbrenner.
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

Violation
Medical examination report(s) was/were not on file for Meagan Barnett, Brooklyn Glassbrenner, Emma Williams 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

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
Not Observed
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
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
Compliance
5 CSR 25-500.222 Records and Reports
Compliance
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