MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

SCHOOL AGE INSPECTION REPORT

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Facility Information

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

Facility DVN
001779428

Phone
(573) 754-6904

Physical Address
500 HALEY AVE
LOUISIANA
MO 63353-2417

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

Mailing Address
614 KELLY LN
LOUISIANA
MO 63353-2409

Provider/Director
PEDERSEN, TERESA LEE

E-mail Address
Noveta.Shepherd@twinpikefamilyymca.org

Incorporated
Incorporated

Child Care Specialist
SUSAN MARIE DOUGLAS

Age Range
5 YEARS - 13 YEARS

Capacity
96

Facility Type
SCHOOL AGE

Limitations

Inspection Information

Date
11/06/2023

Arrival Time
1:45 PM

Departure Time
2:49 PM

Notice
UNANNOUNCED

Inspection Type
COMPLIANCE MONITORING

Inspection ID
2458262004

Document	Document-Date
SAMPLE FORMS	11/09/2022
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	10/06/2022
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	10/03/2022
JOB RESPONSIBILITIES	07/10/2003
CERTIFICATE OF INCORPORATION	10/29/2003
ANNUAL DECLARATION	10/03/2023
EQUIPMENT LIST	10/03/2023
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS	09/19/2023

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.

Attendance at Time of Inspection

Total Staff 2

Total Children 12

Staff	Child	Class Age	Note
2	12	SCHOOL AGE	Teresa Pederson , director and Olivia Hutt, staff were present with 12 children ages 5 to 10.


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 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 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