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Home My WebLink AboutDaycare Inspection 27 Spieldman Road Post for 30 Department of Public Health-Child Care Licensing Program Page 1 of 2 ''fP grating 410 Capitol Ave,MS 912 DAC ays PO Box 340308 Hartford,CT 06134-0308 800-282-6063/(fax)860-509-7541 CHILD CARE CENTER/GROUP INSPECTION FORM ❑ INITIAL INSPECTION INSPECTION ❑ FOLLOW UP ❑ OTHER Program Name: License Number: Date of �y 1 Time of 'k r i Inspection: Arrival: Address Expiration Date: Licensed 5 Capacity:56 Town: �yy /y Telephone: Under Three E U� 1 ' �z Endorsement: jQ rerator: Licensed For: Instructions: K Number' Children Number of U3 Number of Staff Under Three(6wks-36m) `� =Compliance Present: Present: Present: Preschool(3y-5y) O =Non-Compliance Hours of Operation: Summer Care � School Age(Sy&up) 3 =Not Observed 4 =Not Applicable a w � Yes/No ❑ Night Care(6wks&up) Administration 19a-79-2a Health and Safety 19a-79-6a 1.Local Health Inspection Date:--.,) 0.Nutritious Snacks/Meals(Required Food Groups) Administration 19a-79-3a41.Proper Refrigeration 45° 2.New Staff/Employee Orientation 0 42.Kitchen Separated 3.Annual Staff Training 43.Hand Washing Before Eating/Food Handling " ❑ 4.Documentation of Beh M.Tech Discussed w/Parents Y/N ❑ 44.First Aid Kit(s):Indoor/Outdoor/Field Trip 5.Notification of Change vsical Plant 19a-79-7a +13 6.Policies:Discipline/Supervision/Child Protection/General 45.License Premise Clean/,Ggod Repair/Safe Operating Policies/Personnel Policies/Closing Time Policy 46.Peeling Paint Observed Y T,Sample Taken: 7.Daily Attendance Records:Children/Staff ❑ 47.Lead Management Plan Reviewed:Y/N �-Items Posted-Conspicuous/Accessible 48.Sanitary Drinking Fountains ispos ble Cups N 8.License ] 49.Lead Water Test Date: 9.Current Fire Marshal Certificate Date: Q ` Within Acceptable L' its /N 10.DPH Complaint Procedure ` 1 On Bottled Water t( ❑ 11.Food Service Certificate Date a`@! 50.Walkways Maintained 12.Menus �pj 51 Designated Staff Toilet/Sink 13.Emergency Plans 52'All Openings for Ventilation Screened 14.No Smoking Signs k 1 53.Windows Protected to Prevent Falls 15.Radon Test Date: 112AO I Results<)S i �fj 54.Glass Protected to 36" Staffing 19a-794a C- 55.Overhead Doors:Locking Devices/Spring Protectors 16. Staff Health Records V 56.Exits/Hallways and Stairs Unobstructed **191 17. Professional Development 57.Individual Storage of Clothing/Bedding ❑ 18.Disciplinary Actions 58.Smoking Prohibited �� 19.Designated Head Teacher/60% `� 59.Matches/Lighters Inaccessible ` . 20.Two Staff Present 60.Approved Safety Outlets/Covers 'W] 21.Ratio: 1 Staff to 10 Children `VVj 61.Toileting Needs Met 22.Group Size:Maximum 20 Children 62.Required Toilets/Sinks/Supplies 23.Designated Director 63.Potty Chairs:Nonporous/Emptied/Disinfected 24.CPR Certified Staff 64.Hand Washing After Toileting:Staff/Children 25.First Aid Trained Staff 65.Ventilation in Toilet Room Consultants 19a-794a 66.Air Temp 65°,Thermometer Affixed ❑ 26.Agreements/Contracts(Signed Annually) Ix 67.Water Temperature 600-11 ° ❑ 27.Logs/Visits Documented 68.Portable Space Heaters Y Early Ch.Education Health_ Dental 69.Walls/Ceilings/Floors/Rugs:Clean/Good Repair Social Service_ Dietitian_ 70.Rugs Secured Swimming 19a-794a 71.Hot Water/Steam Pipes Protected ❑ 28.Non-Swimmers Identified \ 72.Working Phone on Each Level ❑ 29.Staff/Child Ratios y 73.Emergency Numbers Posted ❑ 30.CPR Certified Staff(20 years of age) 74.Adequate Lighting:50/30 Candle Feet El31.Lifeguard Certified/Supervision ❑ 75.Light Fixtures Shielded/Shatter Proof Record Keeping 19a-79-5a `�5e7 76.Potentially Hazardous Substances Locked Enrollment Information �°6ej 77.Garbage/Rubbish Disposed Daily 7 33.Emergency Medical Permission 78.Stairs Protected/Good Repair/Handrails 34.Authorized Released Permission 79.Pets:Maintained/Care Plan ❑ 35.Field Trip Permission 80.Operable CO Detector on Each Level 36.Transportation Permission 81.Program Space/Adequate Sq.Ft.Per Child ❑ 37.Child Health Records/Immunizations/TB 82.Equipment-Clean/Good Repair/Safe/Non-toxic ` -, 38.Individual Care Plan(Signed by Parent/Staff) 83.Cots Stored/Maintained/Adequate Number �A 39.Injury/Illuess/Accident Reports 84.Developmentally Appr.Equipment/Materials Signature of Inspector Written Corrective Action Plan Sig Lure of Person in Charge Due to DPH by: Pont for 30 Page 2 of 2 pikratint . Days CHILD CARE CENTER/GROUP INSPECTION FORM Program Name: License Number: Date of Inspection: t �.o ) i0 85.UA Tu s/Spas/Saunas: Locked/inaccessible V 1.25.Children's Linens/Clothing/Bedding Stored 86.No Weapons/No Facsimile of a Firearm on Premises Individually Outdoor Space � 126.Cribs/Cots Washed/Disinfected 87.Outdoor Space Adequate Sq.Ft.Per Child ` - 127.Under 12 Months Placed on Back for Sleeping 88. Impact Absorbing Material under Equipment ) 128.Alternate Sleep Position/FM3pment 89.Playground Free from[Wards Medical Documentation ❑ 90.Peeling Paint Observed,Sample Taken: 129.Crib/Bed Used for infant Sleeping 91.Lead Management Plan Reviewed: Y/N ❑ 130.CribBed Free from Observable Hazards 92.Equipment Anchored/Safely Arranged 131. Infant Toys Separate/Washed/Disinfected Daily 93.Outdoor Play Area Protected/Fenced N 132.No Toys/Objects Less than 1 `Y."Diameter 94.Drinking Water Available/Accessible ` 133.Plastic Bags/Balloons/Styrofoam Objects Inaccessible j 134.Health Consultant/Documentation of Visits `Educational Requirements 19a-79-8a � 135. Infants Held for Bottles/Indiv.Attn/Tummy Time vfl 95.Written Plan for Daily Program Available to 136.Written Statement/Feeding Schedule from Parent NaParents/Staff 137.Unused Portions of Liquids Discarded ` 96.Activity Choices I clude: \�- 138.Clean Bottles/Disp.Bottles/Approved Bottle Washing Indoor/Outdoor V Fine/Gross Motor 139.Food Served from Dish or Whole Jar Served Language Sensory \so 140.Bottles Individually Identified w/Child's Name Art/Media Dramatic Play Outdoor Play Space-Under Three Music Self Concept 141.Play Space Fenced Health Education Active/Quiet 142.Outdoor Equipment Available/ Child/Staff Initiate Exploration Developmentally Appropriate Varied Choices \ Indiv/Small Gro Snacks/Meals \i Toileting/Clean Up School Aee Children Endorsement 19a-79-11 ' rj 143.Approved Endorsement Administration of Medications 19a-79-9a 144.Activity Choices Include: Nd 97.Written Policies/Procedures Free Time _Creative_Homework _ 98.Training Outline/Med Training Snacks _ Physical_Special Events_ Nonprescription Topical Medications Small Group_Quiet _Self Concept \� 99. Administration/Parent Permission 145.Ratio: I Staff to 10 Children `Vr1 100. Labeling/Storage 1�`6d 146.Group Size:Max.20 Children `54 101. Trained Person PresentlWritten Approval 147.Education Consultant Appropriate raVropical/Inhalant/Injectable Medications 102. Authorized Prescriber/Parent Permission/MAR ight Care Endorsement 19a-79-12(10om-5am) 103. Labeling/Storage ❑ 148.Approved Endorsement �] 104. Unused/Expired Meds Returned/Disposed Y N ❑ 149.Written Plan:Program Activities/Supervision Self Administration ❑ 150.All Staff Awake/Available ❑ 105. Authorized Prescriber/Parent Permission/MAR ❑ 151.Individual Cot/Crib/Bedding/Toiletries/ ❑ 106. .Labeling/Storage Sleeping Apparel ❑ 107.Appvd Petition For Special Medication Authorization ❑ 152.Sleeping Apparel/Toiletries Individually Emergency Distribution of Potassium Iodide Labeled/Stored ❑ 108. Parent Permission/Storage ❑ 153.Bedding/Sleeping Apparel Laundered Weekly Under Three Endorsement 19a-79-10 Monitoring of Diabetes 19a-79-13 Nj 109.Approved Endorsement ❑ 154.Written Policies/Procedures 110.Ratio: i Staff to 4 Children El155.On Site Staff Trained in First Aid/Glucose Testing 111.Group Size no Larger than 8 ❑ 156.Training Current/Documented 112.Physical Barriers/Groups of 8(Indoors/Outdoors) ❑ 157.Supervision of Self Administration 113.Adequate Sinks in Program Space ❑ 158.Equipment/Supplies: Labeled/Inaccessible 114.Free Standing Cribs ❑ 159.Signed Agreement w/Parent Regarding Equipment 115.Washable Cots ❑ t60.Materials to be Discarded: Locked/ 116.Chairs for Feeding/Stable/Safety Straps/Locking Tray Given to Parent 117.Dev.Appropriate Tables/Chairs/Equipment ❑ 161.Authorized Prescriber/Parent Permission 118.Refrigerators and Food Prep Facilities ❑ 162.Documentation of Test Results/ Diapering Area _ Action Taken ❑ 119.Sturdy/Safety Rai onporous Exclusive Use ❑ 163.Daily Written Parent Notification `1Q 120.Washed/Disinfected 121.Disposable Paper Sheets 122.Covered Waste Receptacle 123.Diaper Changing Policy Posted/Followed 124.Hand Washing Policy Posted/Followed Signature of Inspector Written Corrective Action Plan Sig ure of Person in Charge Due to DPH by: r I INSPECTION ❑ REINSPECTION ❑ COMPLAINT ❑ INVESTIGATION ❑ OTHER REPORT OF INSPECTION TO GROUP DAY CARE HOME OR CHILD DAY CARE CENTER NAME OF CENTER: t►1 t� C' rp DATE-(A TIME: DIRECTOR: fC,`6 CAPACITY: #PRESENT: C� ADDRESS: ?r Iri}'ice rT) I STAFF PRESENT: t ik U3 f r-,d � L� EXPIRATION DATE: 1201 2n.i TELEPHONE#= c4L LICENSE NUMBER_ PURPOSE OF VISIT:{Y-\ � C OBSERVATIONS/CORRECTION NEEDED: 0-Yr` "111C. 1� 1�;��.s� ifs-..��. �;� r.�- �.�t.»-,� c'� ��.J�•P� `�Ch�z�`�'-" kz i� R � Wit , Ya �r'ic �`� tl� iC"t �Ec 4�5a cis Slims+nct ylrtC t ,J �"F �: `etc:=� �'�c��..:�•E: ��c�� Imo,� �r ..a t71 e r ti --6 -�`t:<x r5`f-ta i 1 l o `�tl [�..��F ��t B`��Je"t€�` t�t�v-r G -t =,Arxbkz, irp pooro-L 5aTi rr P4 - -� � erg �`'p��-t i r•r TY S=Substantiated NS=Not Substantiated P=Pending If applicable) DATE CORRECTIONS DUE. °- j SIGNED: ,_- (lrtspector-DPH) SIGNED: ' (Person in Charge) s./Division/LicensurctGrp&ctr/Field Forms/Report of Inspection 11/5/03 ENVIRONMENTAL INSPECTION REPORT ❑ INSPECTION A -SREINSPECTION ❑ COMPLAINT Ajon-� Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 —"29'-+0 Date of Inspection INSTRUCTIONS Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable' Date of Expiration Licensed Capacity Under 3 Endorsements #Children Present #Staff Present An Program Na / License# Telephone# Address /► Operator Licensed for: Under 3 Yrs S LP chool Age ❑Nigbt Care re-School(3-5 Years) El On Site Kindergarten Physical Plant/Indoor Space 19a-79-7a Health and Safety 19a-79-6a ❑ 1 License premises clean/good repair ❑ 11 Refrigeration no more than 450 ❑ 2 Equipment clean,in good repair,safe/non-toxic ❑ 12 Food prep area clean/good repair ❑ 3 Free from observable hazards ❑ 13 Food safely stored ❑ 4 Drinking water available,adequate,safe ❑ 14 Food prep handwashing ❑ 4a Lead Water Test/Date ❑ 15 Adequate dishwashing ❑ Within Limits ❑ Exceeds Limits ❑ 16 Kitchen separated ❑ 4b Public Water Supply ❑ 17 Mark as appropriate: ❑ 4c On Site Well(In compliance with CT Public Health Code ❑ Snacks served ❑ Cold breakfast Sections 19-13-B51a-m and 19-13-11102) ❑ Meals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year ❑ Building: Post 1978 Construction ❑ 4d Private Well—Facility serves less than 25 children&adults f Building: Pre 1979 Construction(Lead Inspection Required) ❑ 4e Other(Please specify) ❑ No Lead-Based Paint Identified ❑ 5 Required toilets/sinks/supplies Lead Hazards Identified and Eliminated ❑ 6 Adequate ventilation in toilet room ❑ 7 Sewage disposal adequate (Plan of correction on file with Local Health Dept(LHp)) ❑ Intact Lead-Based Paint Identified (Management Plan on file with LHD) Outdoor Space 19a-79-7a ❑ 8 Swimming pool complies with PHC 19-13-B33b ❑ 9 Playground free from observable hazards "REMARKS" ❑ 10 Drinking water available,adequate,safe ❑ Approval recommended. No code violations identified. ❑ Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code violations. Ali- 1 1p aSoCi v ��v� 7�iiuo /ca ne c Date Corrections Due Signed(Person in Charge) s:/Di ' o nsure rp ctr field Forms/Env Inspection Report 3/05/03 Website form for Local Health ENVIRONMENTAL INSPECTION REPORT INSPECTION ❑ REINSPECTION ❑ COMPLAINT S-,�✓`` Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 r /D Date of Inspection INSTRUCTIONS ,I—on--/ 0 Check=Compliance, Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity oL � Under 3 Endorsement U #Children Present_ #Staff Present_ ZE Progr-aim _� License# Telephone l KLI "aA4k Address Operator Licensed for: Under 3 Yrs �"chool Age ❑Night Care XPre-School(3-5 Years) ❑On Site Kindergarten P ><cal Plant/indoor Space 19a-79-7a Health and Safety 19a-79-6a License premises clean/good repair ❑ 11 Refrigeration no more than 45° 2 Equipment clean,in good repair,safe/non-toxic ❑ 12 . Food prep area clean/good repair❑�3 Free from observable hazards ❑ P 13 Food safely stored I ffJ. Drinking water available,adequate,safe ❑ 14 Food prep handwashing L 9'4a Lead Water Test/Date ❑ 15 Adequate dishwashing ❑ Within Limits El Limits ❑ 16 Kitchen separated 4b00' Public Water Supply ❑ 17 Mark as appropriate: ❑ 4c q On Site Well(In compliance with CT Public Health Code 6.Snacks served ❑ Cold breakfast Sections 19-13-B51a-m and 19-13-11102) ❑ Meals served ❑ Meals transported ❑Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year wilding: Post 1978 Construction ❑ 4d Private Well-Facility serves less than 25 children&adults Building: Pre 1979 Construction(Lead Inspection Required) ❑ 4 Other(Please specify) ❑ No Lead-Based Paint Identified Required toilets/sinks/supplies ^� Adequate ventilation in toilet room ❑ Lead Hazards Identified and Eliminated fly"i Sewage disposal adequate (Plan of correction on file with Local Health Dept.(LHD)) ❑ Intact Lead-Based Paint Identified (Management Plan on file with LHD) Outdoor Space 19a-79-7a LL4N, F-DOt- d TTAC' ❑ 8 Swimming pool complies with PHC 19-13-B33b qA eN(; ❑ 9 Playground free from observable hazards "REMARKS" ❑ 10 Drinking water available,adequate,safe ®"Approval recommended. No code violations identified. ❑ Approval recommended with conditions(see below). ❑ Approval not recommended due to existing serious code �Y b 7— J 1 , L violations. Jy s 7'I j-AS 1 N ate.-sduab r Sig ns D4te Corrections Due Signed s n a ) r s:/Drvis icensure/Grp&ctr/Field Forms/Env Inspection Report 3/05/03 Website rm for Local Health Robert DeVito Town of South Windsor 1540 Sullivan Avenue South Windsor, CT 06074 Robert, First Of all,thanks for being so cooperative with regards to this lead abatement order. Here are our plans for addressing the your specific request on numbers 121, 122, 123 and 125 from our lead inspection report dated 11/19/2007. We have retained the services of Joe Valenti of Valenti's Painting in East Hartford (922- 0480) to completely remove the door, door jamb and threshold that tested positive and replace them. I found Valenti's Painting on the State of CT's approved lead abatement contractor list. This work will be done before the end of July. With regards to the other areas that tested positive,we will be maintaining a weekly log in our preschool and Toddler 3 rooms to make sure that the areas that have tested positive are intact and exhibit no signs of chipping and/or peeling. In the preschool bathroom and closet, where the lead paint had been covered by sheetrock/joint compound,we will maintain a monthly log. Please let me know if you have any additional questions. I will submit the paperwork from the lead abatement work as soon as the job is complete. Thanks again for your patience. Sincerely, Jeff Welch Rising Stars Childcare 150 Burnham St. South Windsor,CT 06074 Renee Welch Phone:860-528-7529 Owner/Director Email:risingstarsct@att.net ENVIRONMENTAL INSPECTION REPORT ❑ INSPECTION ❑ REINSPECTION ❑ COMPLAINT ,5�•1 wc�ra^ Department of Public Health-Child Care Licensing Program Town 410 Capitol Ave.,MS#12 DAC,P.O.Box 340308,Hartford,Connecticut 06134-0308 A— Date of Ins ection INSTRUCTIONS -�� ,L,:d, Check=Compliance; Circle=Non-Compliance; 3=Not Observed; 4=Not Applicable Date of Expiration Licensed Capacity Under 3 Endorsement ,7 #Children Present #Staff Present Qi�Inc 'Atri, Cllad 4&C &0/2- ram /� dt►'ds Program Name License# Telephone# 27 Address Operator Licensed for: MlTnder 3 Yrs [School Age ❑Night Care re-School(3-5 Years) ❑On Site Kindergarten Physical Plant/Indoor Space 19a-79-7a health and Safety 19a-79-6a o vpC Q' License premises clean/good repair OT 11 Refrigeration no more than 45 e4f 1i Equipment clean,in good repair,safe/non-toxic 912 Food prep area clean/good repair 3 Free from observable hazards 13 Food safely stored ❑ 4 Drinking water available,adequate,§afe /� 14 Food prep handwashing ❑ 4a Lead Water Test/Date a f a' 15 Adequate dishwashing ,-, [I Within Limits El Exceeds Limits 16 Kitchen separated 94o Public Water Supply 1 17 Mar s appropriate: ® 4c On Site Well(In compliance with CT Public Health Code Snacks served ❑ Cold breakfast 1 Sections 19-13-B51a-m and 19-13-11102) Meals served ❑ Meals transported Local Health verified with DPH Water Supplies Section for ❑ Other facility licensed to serve 25 or more adults and children over 60 days per year ❑ ilding: Post 1978 Construction 4d Private Well—Facility serves less than 25 children&adults gilding• Pre 1979 Construction(Lead Inspection Required) ❑ 4e Other(Please specify) ❑ No Lead-Based Paint Identified ❑ 5 Required toilets/sinks/supplies 4..f#iv / (1 �� 6 Adequate ventilation in toilet room [ead Hazards Identified and Eliminated �;K7 Sewage disposal adequate Plan of correction on file with Local Health Dept.(LHD)) ntact Lead-Based Paint Identified (Management Pl`arl on file with LHD) Outdoor Space 19a-79-7a kf bn 8 Swimming pool complies with PHC 19-13-B336 V10 Playground free from observable hazards "REMARKS" Drinking water available,adequate,safe ❑ &pproval recommended. No code violations identified. �/l ry ®ham pf,�tvi 14014- pv,",f proval recommended with conditions(see below). ��f El Approval not recommended due to existing serious code violations. One ��f Ny 1^e cJ rr� led P144 Signed(Inspector) Date Corrections Due Si d(Pwo 'n Ch rg s:/Division/Licensure/Grp&ctr/Field Fo s/Env Inspection Report 3/05/03 Website form for Loca ea th 10W N Se o x t- O-PS' � c � a ` 1540 SULLIVAN AVENUE• SOUTH WINDSOR, CT 06074 °soe CO TELEPHONE (860) 644-2511 June 11, 2009 Rising Stars Child Care, LLC Renee Welch 150 Burnham Street South Windsor, CT 06074 Re: Lead abatement and monitoring plan for Rising Stars Child Care, LLC, at 150 Burnham Street. Dear Ms. Welch: Julie Boscarino,Department of Public Health, Child Care Licensing Specialist,has informed this office that during her most recent inspection she observed the entrances in the western portion of the building had peeling paint. You may recall that these areas received positive readings during the lead inspection conducted on November 19, 2007, and are listed on the Positive Reading Summary portion of the report as numbers 121, 122, 123, and 125. At that time they should have been part of the lead abatement plan submitted to this office in December 2007. A review of our files has confirmed that these positive areas were not part of the abatement plan, not abated and as a result they now must be addressed. Please submit a lead abatement plan to this office for review no later than July 11,2009, which should be accompanied by a monitoring plan that indicates how tall the positive areas will be monitored. These plans and the abatement work must be submitted and performed by a licensed lead abatement contractor. If you have any questions I can be reached at 860-644-2511, extension 248. Very truly yours, Robert De Vito, R.S. Environmental Health Officer CC: Julie Boscarino, Child Care Licensing Specialist CHILD DAY CARE CENTER AND GROUP DAY CARE HOME INITIAL LICENSING CORRECTIVE ACTION REPORT NAME OF CENTER/HOME: RISING STARS CHILDCARE, LLC LOCATION ADDRESS: 27 SPIELMAN ROAD SOUTH WINDSOR, CT 06074 TELEPHONE NUMBER: 860-528-7529 LICENSE NUMBER: PENDING A COMPREHENSIVE LEAD INSPECTION WAS COMPLETED ON NOVEMSER 16,2007. THE FOLLOWING IS A CORRECTIVE PLAN TO ENSURE THAT THE AREAS THAT TESTED POSITIVE FOR LEAD PAINT ARE IN COMPLIANCE WITH STATE OF CONNECTICUT REGULATIONS. ITEM#/VIOLATION# DESCRIBE HOW THE VIOLATIONS WERE CORRECTEFFOZATIONS FROM INSPECTION MEASURES HAVE BEEN PUT IN PLACE TO ENSURE T REPORT VIOLATIONS DO NOT RECUR RECTED Based on the Lead Inspector's report, half of the Preschool bathroom tested positive for lead paint. Our corrective plan is to sheet rock over all of the exposed 19a-79-7(C)(2) areas and repaint the the entire room. The Director will Physical Plant ensure that every Monday a visual inspection of each General surface is conducted and checked for chipping,in g, peeling Requirements 7 scratched or missing paint. 12/31/2007 Based on the Lead Inspector's report, the Preschool broom closet tested positive for lead paint. This entire 19a-79-7(C)(2) area will be covered with joint compound, primed and Physical Plant painted. The Director will ensure that every Monday a General visual inspection of each surface is conducted and Requirements I checked for chipping, peeling scratched or missing paint. 12/31/2007 lye T0-0,A , s After e� 5�, STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH LEAD INSPECTION REPORT FORM This lead inspection report form must be completed and sent to the property owner,local director of health and the commissioner of the Department of Public Health in accordance with Section 19a-I11-3(d)of the regulations of Connecticut State Agencies concerning Lead Poisoning Prevention and Control. PROPERTY INSPECTED Street Address: Z 7 SD i c(mot., Apt.# Floor: City/Town: S ov+k I/V iK&So r Zip Code: 06 b 7 Y Telephone: 52 E'-7_ r2? If Apartment,Number of Units: Year Property Built: PROPERTY OWNER Name: Street Address: City: State: Zip Code: Telephone: INSPECTING ENTITY A. If Consultant Contractor: 1 Name: C 7' t.Ca d pcy, j•' seb i A toss Street Address: 1.2 qsr H e b Now A v t City: 6f -t- g 0 a r State: C T Zip Code: 0 6 O-73 Consultant License Number: 2/2 V Inspector's Name: An 4 -c w tCr Telephone: eCO 63 33 3 G Inspector's Certification Number: 04 00 217 2 B. If Code Enforcement Agency: Department Name: Street Address: Town/City Department: Telephone: Inspector's Name: Telephone: Date of Inspector's Initial Training: / / Date of Latest Refresher Training: Phone: (860) 509-7299, Fax: (860) 509-7295 Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue-MS 4 51LED P.O. Box 340308 Hartford, CT 06134 An Equal Opportunity Employer INSPECTION INFORMATION Date(s)of Inspection: 1 e / 17 /d 7 For each day the inspection was conducted Consent was given by an adult occupant of the dwelling unit to enter and inspect all areas of the dwelling that are under the control of that individual or to which that individual has legitimate access. ,NYes ❑No Name of person granting consent: SG��►` WG(C It Date: I 1/1 7/a7 Name of person granting consent: Date: Name of person granting consent: Date: Were Lead-Based Surfaces Identified? (Please check) Yes ❑No If yes,check appropriate box(es)below and attach"LEAD BASED PAINT DATA PAGES" ® Interior Defective Surfaces ❑Exterior Defective Surfaces (� Interior Intact Surfaces ❑ Exterior Intact Surfaces Indicate Potential Sources of Lead Identified ❑ Paint(exterior) ❑ Soil ❑Water r'ea 14s, OR e*4 cis r' -%, r. ° F ' 1/2 y!O7 ®Paint(interior) ❑ Dust ❑ Other: o Was drinking water exposure pathway investigated and the potential for lead poisoning to a child assessed?0 Yes ❑No If yes,list sampling locations: r'Ccg&. IT.+Ct-e. Fewc.6 ✓rC1, +C, D ev.cl�r.a o Was dust exposure pathway investigated and the potential for lead poisoning to child assessed? Yes ❑No If yes,list area(s)tested: Sea o Was soil exposure pathway investigated and the potential for lead poisoning to child assessed? �� Yes ❑No If soil samples were collected,document soil sampling methodology below: sec. e1T gC14{ d V`G.p0 Gp✓vec �vG 4C ♦o►M Is a leader!-plant required for this property per section 19a-1114(a)of the Connecticut State Regulations concerning Lead Poisoning Prevention and Control? (A lead management plan for this property may be required per Section 19a-111-2(e)of the Connecticut State Regulations concerning Lead Poisoning Prevention and Control). OYes ❑ No The federal Residential Lead-Based Paint Hazard Reduction Act,42 U.S.C.4852d,requires sellers and landlords of most residential housing built before 1978 to disclose all available records and reports concerning lead-based paint and/or lead-based paint hazards, including the test results contained or referenced in this notice,to purchasers and tenants at the time of sale or lease or upon lease renewal. This disclosure must occur even if hazard reduction or abatement has been completed. Failure to disclose these test results is a violation of the U.S.Department of Housing and Urban Development and the U.S.Environmental Protection Agency regulations at 24 CFR Part 35 and 40 CFR Part 745 and can result in a fine of up to$11,000 per violation. To find out more information about your obligations under federal lead-based paint requirements,call 1-800-424-LEAD. Inspector's Signature: Dated: ` l 2 y l - Mail To: State of Connecticut-Department of Public Health Division of Environmental Health P.O.Box 340308,MS#51LED Hartford,CT 06134-0308 03/03/03 Positive Reading Summary Paint Page 1 Connecticut Lead Paint Solutions 1245 Hebron Ave,Glastonbury,CT 06033 860-633-3330 Since1993 Serial#XL309-U4306NR8622 Site: 27 Spielman Rd,South Windsor,CT 06074 Date: 11/17/2007 No Fir Side Room Comp Sub Feat Cond Color Result Pbc*Prec 61 1 D P-1 Kit.area Closet Wood Cleat Fair White POS 1.81 t 0.56 62 1 D P-1 Kit.area Closet Wood Cleat Fair White POS 3.11 f 1.21 63 1 D P-1 Kit. area Closet Plaster Wall Peeling White POS 4.04 t 1.37 69 1 D P-1 Kit. area Wall Plaster Intact Beige POS 1.16 f 0.45 70 1 D P-1 Kit. area Wall Plaster Intact Beige POS 1.61 ± 0.58 79 1 B P-1 Bath Wall Rht Plaster Poor Blue POS 2.57 t 1.17 80 1 C P-1 Bath Wall Plaster Poor Blue POS 2.96± 1.31 81 1 D P-1 Bath Wall Lft Plaster Poor Blue POS 2.02 t 0.89 121 1 C Front Entr. Door Wood Fair Red POS 17.18 t 8.01 ,�,122 1 C Front Entr. Door Wood Fair Red POS 16.99± 7.48 123 I C Front Entr. Door Wood Jamb(1st 311) Intact Wallpaper POS 7.15 t 2.38 125 1 C Front Entr. Door Wood Threshold Fair Beige POS 1.31 f 0.26 This is a summary of all positive readings determined during the inspection, on both interior and exterior surfaces. It should be assumed that any similar component in the same room or area is also positive for LBP. Assume that walls A and B in the P-1 Kitchen Area are also positive for LBP. ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 4 804-275-4788 FAX 804-275-4907 WIPE LEAD ANALYSIS SUMMARY CLIENT: CT Lead Paint Solutions,Inc DATE OF SAMPLING: 17 Nov 2007 1245 Hebron Avenue DATE OF RECEIPT: 21 Nov 2007 Glastonbury, CT 06033 DATE OF ANALYSIS: 21 Nov 2007 DATE OF REPORT: 23 Nov 2007 CLIENT NUMBER: 7-1566 D EHS PROJECT#: 2007-11-2015 PROJECT: 07-0352 EHS CLIENT WIPE TOTAL CONCENTRATION SAMPLE# SAMPLE# AREA(ft22) LEAD(uq) (ug/ft2) 01 D W-1 1.00 <20 <20 02 DW-2 0.646 <20 <31 03 DW-3 1.00 <20 <20 QUALITY CONTROL DATA BATCH#: 112107W-14 INCLUSIVE EHS SAMPLE NUMBERS: 01-03 Continuing Calibration Verification 10(10.Oppm Pb) 96.8%Recovery Continuing Calibration Verification 5 (5.00ppm Pb) 100% Recovery Laboratory Control Standard 91.2%Recovery Matrix Spike 91.8%Recovery Duplicate Relative Percent Difference 0.656 RPD Reporting Limit 20ug Method Detection Limit 3.0ug PREPARATION METHOD: ASTM E 1979-98M ANALYSIS METHOD: EPA SW846 7420 ANALYST: Al Simonds Reviewed By Authorized Signatory: Michael A.Muelle , H, La o atory Director Howard Varner, General Ma g r Irma Faszewski, Quality Assurance Coordinator David Xu,MS, Senior Chemist Sample results denoted with a"less than"(<)sign contain less than 20ug total lead,based on a 40ml sample volume. The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description,area,volume etc.,was provided by the client. If the report does not contain the result for a field blank,it is due to the fact that the client did not include a field blank with their samples. EHS sample results do not reflect blank correction. This report shall not be reproduced, except in full, without the written consent of Environmental Hazards Services,L.L.C.California Certification#2319 NY ELAP#11714 LEGEND ug=microgram ppm=parts per million uglft2=micrograms per square foot ml=milliliter Pb=lead ft2=square foot wipepb 15.AA220.dot/13MAR2007/R EV3/MR/pd --PAGE 01 of 01 --END OF REPORT-- Environmental Hazards Services, LLC 7469 White Pine Road Richmond, Virginia 23237 EHs 2007-11-2M 804-275-4783 CHAIN OF CUSTODY FORM Date: November 19, 2007 Bill to; CT Lead Paint Solutiions' Company Name: CT Lead Paint Solutions Address: 1245 Hebron Ave. City, State, Zip Glastonbury, CT 06033 E-mail to; Phone: 860-633-3330 andrew@leadtests.com Project Name: Creative Kidz Child Care Dates of Collections: Assessment Tests November 17, 2007 Project Address: 27 Spielman Rd, South Windsor, CT 06074 Project Number 07-0352 Matrix Method Instrument Method Detect Limits TAT Lead in Paint NIOSH 7082M Flame Atomic Absorption 3.0 ug/wipe 24 hours Ghost Wipes Used Lead. in Dust Sample # Area size/ Location Sample and substrate Area Lab s uare inch notes DW-1 144.00 Floor, C side vinyl Bath #1 C.. DW-2 93.00 C side, Wind. sill, wood Bath #1 DW-3 144.00 Floor Cside, vinyl Cubby Area Collected Andrew Miller Signature Date: Nov. 17, 2007 Mailed.bL Andrew Miller Signature Date: Nov. 19, 2007 Received Signature Date: b ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 74 7 804-275-4788 FAX$04-275-4907 LEAD IN SOIL ANALYSIS SUMMARY CLIENT: CT Lead Paint Solutions,Inc DATE OF SAMPLING: 17 Nov 2007 1245 Hebron Avenue DATE OF RECEIPT: 21 Nov 2007 Glastonbury, CT 06033 DATE OF ANALYSIS: 21 Nov 2007 DATE OF REPORT: 21 Nov 2007 CLIENT NUMBER: 7-1566 D EHS PROJECT#: 2007-11-2014 PROJECT: 07-0352 EHS CLIENT CONCENTRATION SAMPLE# SAMPLE# PPM (mg/kg) 01 Soil-1 <48 02 Soil-2 <46 QUALITY CONTROL DATA BATCH#: 112107S-2 INCLUSIVE EHS SAMPLE NUMBERS: 01-02 Continuing Calibration Verification 5 (5.00ppm Pb) 90.6%Recovery Laboratory Control Standard 83.2%Recovery Matrix Spike 97.2%Recovery Duplicate Relative Percent Difference 7.41 RPD Reporting Limit 20ug - Method Detection Limit 2.9ug PREPARATION METHOD: EPA 600/R-93/200 ANALYSIS METHOD: EPA SW846 7420 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory: � s � Michael A. Mueller,MPH,Laboratory Director Howard Varner,General Manager Irma Faszewski, Quality Assurance Coordinator David Xu,MS, Senior Chemist Sample results denoted with a"less than"(<)sign contain less than 20ug total lead,based on a 40ml sample volume. The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description,area,volume etc.,was provided by the client. This report shall not be reproduced, except in full, without the written consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY ELAP#11714 LEGEND ug=microgram ppm=parts per million mg/kg=milligrams per kilogram ml=milliliter Pb=lead so i Ipb3.dot/AA220AF S/07 MAR2006/R EV2/MR/ --PAGE 01 of 01 --END OF REPORT-- r Zb Environmental Hazards Services, LLC 7469 White Pine Road Richmond, Virginia 23237 804-275-4788 EHs 2407-1 1-201 CHAIN OF CUSTODY FORM . Date: November 19, 2007 Bill to; CT Lead Paint Solutions Company Name: CT Lead Paint Solutions Address: 1245 Hebron Ave. City, State, Zip Glastonbury, CT 06033 E-mail to; Phone: 860-633-3330 andrew@leadtests.com Project Name: Creative Kidz Child Care Dates of Collections: Assessment Tests November 17, 2007 Project Address: 27 Spielman Rd, South Windsor, CT 06074 Project Number 07-0352 Matrix Method Instrument mdls TAT Lead in Soil EPA846-7420 Flame Atomic Absorption 20mg/kg 24 hours 20 ppm Lead in Soil Sample # Exterior Area Location Sample Comments Lab notes Soil- 1 Pre-School Playground Area 8 comp. samples Soil- 2 Infant Playground Area 8 comp. sam les Collected from bare soil `\ Near play equipment Note; lab, please mix soil sample Collected Andrew Miller Sianature Date: Nov. 17, 2007 Mailed by , Andrew Miller /Signati4re Date: Nov. 19, 2007 Received f; i re �, Date: WJ b r , ' I _�D Z VY A-tip merry- Se. Connecticut Lead Paint Solutions 1245 Hebron Avenue Lead Paint Inspections&Testing Glastonbury,CT 06033 Consulting&Cost Analysis 860-633-3330 Abatement/Management Plans CT License#2124 Abatement&Clean-up Support@leadtests.com Andrew Miller, Inspector Connecticut Lead Consultant and Contractor License#002124 Connecticut Lead Inspector#001127 This report is prepared for; Creative Kidz Child Care 27 Spielman Rd South Windsor, CT 06074 The property inspected was; 27 Spielman Rd, (I" floor front only) South Windsor, CT 06074 The testing instrument used was a Niton XL 309 Duel Detector, Spectrum Analyzer Lead Detector, serial#U4306. A reading of 1.0 milligrams lead per square centimeter of surface (1.Omg/cm2) or greater is defined as a toxic level of lead, by the State of Connecticut, Dept. of Health Services, Regulations for Lead Poisoning Prevention and Control, 19a-111-1 a. At the beginning and end of the inspection, calibration tests are done on known control standards and the readings recorded to ensure the accuracy of the testing device. The calibration line on the data sheets provides the measured lead concentration of the control standards (in the Color column) and whether the lead is at the surface or buried under non-leaded paint (in the Cond column). The testing protocol is to test representative samples of various building components or sub- components per room or area. The test result for the representative sample is then applied to the other similar component(s) in that room or area. Refer to the floor plan attach toward the end of this report for the location of the rooms and walls sides (A, 13, C, D). Any lead reading 1.Omg/cmZ or greater is positive for toxic levels of lead and the line for that reading is in bold print on the data sheets. This inspection is for lead in paint primarily. Dust and soil samples were also collected for analysis of lead concentrations by an accredited laboratory. The test results are included. The test results for lead in water and the radon are pending. The inspection was done on November 17, 2007. The property inspected is a day care facility. It is located in a house likely built in the early 1930's with an addition built after 1986. All rooms or areas in the 1" floor of the original house plus the v attached room(P-1 play area) of the 1980's addition were inspected.No testing was done in any other interior areas, except for a set of French door in a rear class room. All of the windows in the original house have been replaced with vinyl replacement window units. The windows in room P-1 (play area) are newer wood windows with vinyl exterior frames. Most of the interior surfaces that were tested were negative for lead-based paint (LBP). Some LBP was detected on some of the plaster walls in the P-1 kitchen area, including the closet; some, not all, walls in the P-1 bath and the front entrance door and jamb in the future front entrance. All positive surfaces are listed on the page titled Positive Reading Summary. The exterior of the building is completely covered with vinyl siding and vinyl or aluminum trim. Only a few exterior surfaces were painted;all were tested and all were negative for LBP. The play ground equipment appears to be constructed of newer wood or hard plastic. Dust wipe samples were collected in three interior locations for analysis of lead concentrations by an accredited laboratory. All samples were well below the regulatory limits for lead in dust, which are 40ug/ft2 for floors and 250ug/ft2 for window sills. Soil samples were also collected. The bare soil or sand adjacent to play equipment in the Pre-school and Infant play areas were collected for analysis. Both samples were well below the regulatory limits for lead in soil, which starts to become an area of concern for levels exceeding 400ppm. This day care will require a lead corrective action plan and a lead management plan. All of the test results are detailed on the data sheets for the inspection. If you have any questions on this report, please do not hesitate to call. Andrew Miller Lead Inspector/Risk Assessor, CT #002179 November 24, 2007 How to read the data sheets Starting from the left side column. No. The instrument assigns a number to every reading. Flr Indicates which floor the room or areas was on. Side The side of the room that faces the street is the A Side,the B side is clockwise to the A wall, the C wall is opposite the A wall and so on. For the exterior the A side is the front facing the street,the B side is clockwise, the C side is the rear ect. See attached floor plan for more details. Room Indicated which room or area was tested. The room or area is also detailed on the floor plan. Comp. Indicates which building component was tested, window, door, wall ect. The building component may be detailed further in the column called Feat (features). Many components have sub- components such as a window casing or window sash. If there is more than 1 similar building component on a wall in a room or area,than the component may be further described as being the Lft for left, Ctr for center or Rht for right. This would be as you face the wall. Sub. Substrate; indicates what building material the component was constructed of. Feat See Comp above. Cond. Indicates the condition of the paint film or the substrate. The ratings are as follows; intact, a paint film with no cracked or peeling paint; Fair,the paint film is cracked or chipped but paint chips can not be picked off; Poor,the paint film is cracked or chipped and paint chips can be picked off; Peeling; the paint film is very loose and can fall off with little or no external effort. The worse visible condition is noted. Substrate conditions are only listed if it effects the condition of the paint film. Color Indicates the color of the test surface. The color selected is subject to many factors including lighting, contrasting colors, smoke films and others factors. The best choose from a limited number of colors is selected. DI Indicates the depth index which gives the degree of coverage of the lead- based paint by non-lead paint. A DI number of less than 1.5 on a positive reading indicates that the lead is likely on or near the surface. A DI number over 4.0 indicates that the lead is probably deeply buried. The depth index number is not relevant on negative readings. The depth index number is not relevant on negative readings. If the paint film is peeling or defective than the depth index should not be used as a gage of showing that the lead-based paint is safely covered since lead can be exposed if the paint is peeling down to or close to the bare surface. Result Indicates the results of that test. Either POS for positive, equal to or Feater than 1.0 milligrams lead per square centimeter of surface (1.0mg/cm ) NEG for negative, meaning below the action level of 1.0mg/cm2 or INCOM if the reading was interrupted and not completed. The incomplete reading is almost always followed by a complete reading from the same surface. All positive reading lines are in bold print. Pbc This is the range of the lead concentration in the dry paint. Pbl& Pbk The Pbl and Pbk columns show the 2 different ways this testing instrument detects lead in the paint. The Pbl is a shallow reading and will display readings only up to>>5.00mg/cm2. The Pbk is a deep reading. The instrument will pick either or combine them to get a test result (positive or negative) it believes is the most accurate and to determine the Pbc. The prec is the range that the testing instrument has narrowed the reading down to, plus or minus from the main(1 S) number. These columns are not on every report. On the data sheets any lead reading 1.Omg/cm2 or greater is positive for lead-based paint and the line for that reading is in bold print. Paint Page 1 Connecticut Lead Paint Solutions 1245 Hebron Ave,Glastonbury,CT 06033 860-633-3330 Since 1993 Serial#XL309-U4306NR8622 Site: 27 Spielman Rd,South Windsor,CT 06074 Date: 11/17/2007 No Fir Side Room Comp Sub Feat Cond Color Result Pbe± Prec 1 Shutter Cal 1 "' NA 2 Calibration Surface 1.6+/-0.2 POS 1.64+ 0.29 3 Calibration Surface 1.1+/-0.1 POS 1.25 t 0.18 4 Calibration Surface 1.1+/-0.1 POS 1.11 t 0.11 5 Calibration Surface 0.0+/-0.1 NEG 0.00+ 0.04 6 1 A Toddler-3 a Window Rht Wood Sill Intact Brown NEG 0.09 t 0.14 7 1 A Toddler-3 a Window Rht Wood Casing Intact Brown NEG 0.01 + 0.07 8 1 A Toddler-3 a Window Rht Wood Stops Intact Brown NEG 0.09 f 0.19 9 1 D Toddler-3 a Window Rht Wood Sill Intact Brown NEG 0.03 t 0.09 10 1 D Toddler-3 a Window Rht Wood Casing Intact Brown NEG 0.09 t 0.11 it 1 A Toddler-3 a Door Wood Intact Red NEG 0.08+ 0.04 13 1 A Toddler-3 a Door Wood Intact Red NEG 0.12 t 0.15 14 1 A Toddler-3 a Door Wood Panel Intact Red INCOM 0.71 t 0.62 15 1 A Toddler-3 a Door Wood Panel Intact Red NEG 0.06+ 0.07 16 1 A Toddler-3 a Door Wood Jamb Intact Brown NEG 0.04 t 0.10 18 1 A Toddler-3 a Door Wood Casing Intact Brown NEG 0.08+ 0.08 19 1 A Toddler-3 a Door Wood Casing Intact Brown NEG 0.08 f 0.04 20 1 C Toddler-3 a Door Wood Intact Red NEG 0.04 t 0.19 21 1 C Toddler-3 a Door Wood Intact Red NEG 0.08 f 0.29 22 1 C Toddler-3 a Door Wood Casing Intact Brown NEG 0.07 f 0.04 23 1 C Toddler-3 a Door Wood Jamb Intact Brown NEG 0.10 t 0.22 24 1 C Toddler-3 a Opening Rht Wood Casing Intact Brown NEG 0.06+ 0.10 25 1 C Toddler-3 a Wood Baseboard Intact Brown NEG 0.07 f 0.08 26 1 B Toddler-3 a Stairs Wood Newal post Intact Brown NEG 0.11 f 0.14 27 1 B Toddler-3 a Stairs Wood Baluster Intact Brown NEG 0.10 f 0.06 28 l B Toddler-3 a Stairs Wood Stringer Intact Brown NEG 0.20 t 0.13 29 1 A Toddler-3 a Wall Plaster Intact White NEG 0.01 f 0.12 30 1 B Toddler-3 a Wall Plaster Intact White NEG -0.04± 0.80 31 1 C Toddler-3 a Wall Plaster Intact White NEG 0.01 f 0.11 32 1 D Toddler-3 a Wall Plaster Intact White NEG 0.00+ 0.03 33 1 C Toddler-3 a Ceiling Drywall Intact White NEG 0.01 ± 0.03 34 1 D Toddler-3 b Window Rht Wood Sill Fair Brown NEG 0.05 + 0.11 35 1 D Toddler-3 b Window Rht Wood Casing Intact Brown NEG 0.06 t 0.04 36 1 D Toddler-3 b Window Rht Wood Stops Intact Brown NEG 0.08 t 0.11 37 1 A Toddler-3 b Opening Wood Jamb Intact Brown NEG 0.05 t 0.04 38 1 B Toddler-3 b Door Wood Intact Red NEG 0.02 t 0.06 39 1 B Toddler-3 b Door Wood Intact Red NEG 0.03 t 0.21 40 1 B Toddler-3 b Door Wood Casing Intact Brown NEG 0.12 t 0.07 41 1 D Toddler-3 b Cabinet Wood Door Intact Brown NEG 0.00 f 0.12 42 1 D Toddler-3 b Cabinet Wood Frame Intact Brown NEG 0.00+ 0.05 43 1 D Toddler-3 b Cabinet Wood Shelf Intact Brown NEG 0.00 t 0.14 44 1 D Toddler-3 b Cabinet Wood Wall Intact Gold NEG 0.02 t 0.18 45 1 B Toddler-3 b Wood Baseboard Intact Brown NEG 0.07 t 0.03 46 1 A Toddler-3 b Wall Plaster Intact White NEG 0.00+ 0.06 47 1 B Toddler-3 b Wall Plaster Intact White NEG 0.00 t 0.07 48 1 C Toddler-3 b Wall Plaster Intact White NEG 0.00+ 0.06 49 1 D Toddler-3 b Wall Plaster Intact White NEG 0.00 f 0.07 50 1 D Toddler-3 b Ceiling Drywall Intact White NEG -0.52 t 0.84 51 1 B P-1 Kit. area Window Rht Wood Sill Fair Brown NEG 0.02 t 0.23 52 1 B P-I Kit.area Window Rht Wood Casing Intact Brown NEG 0.05+ 0.11 53 1 A P-1 Kit. area Door Lft Wood Intact Red NEG 0.06 t 0.18 Site; 27 Spielman Rd,South Windsor,CT 06074 DatPaint Page 217 No Fir Side Room Comp Sub Feat Cond Color Result Pbc t Prec 54 1 A P-I Kit. area Door Lft Wood Casing Intact Brown NEG 0.10± 0.12 55 1 A P-1 Kit. area Door Rht Wood Intact Red NEG 0.09 t 0.13 56 1 C P-1 Kit. area Door Wood Intact Red NEG 0.00 f 0.16 57 1 C P-1 Kit. area Door Wood Jamb Intact Brown NEG 0.00± 0.04 58 1 D P-1 Kit. area Door Lft Wood Intact Red NEG 0.12 t 0.11 59 1 D P-1 Kit.area Door Lft Wood Jamb Intact Brown NEG 0.07 f 0.07 60 1 D P-1 Kit, area Closet Wood Door Fair Red NEG 0.09± 0.18 61 1 D P-1 Kit.area Closet Wood Cleat Fair White POS 1.81 f 0.56 62 1 D P-1 Kit. area Closet Wood Cleat Fair White POS 3.11 t 1.21 63 1 D P-1 Kit.area Closet Plaster Wall Peeling White POS 4.04 f 1.37 64 1 A P-I Kit.area Metal Radiator Intact Grey NEG 0.01 t 0.13 65 1 A P-1 Kit.area Wall Plaster Intact Beige NEG 0.88 f 0.45 66 1 A P-1 Kit. area Wall Plaster Intact Beige NEG 0.84 t 0.44 67 1 B P-1 Kit. area Wall Plaster Intact Beige NEG 0.81 t 0.44 68 1 C P-I Kit.area Wall Drywall Intact Beige NEG 0.00 f 0.05 69 1 D P-1 Kit. area Wall Plaster Intact Beige POS 1.16± 0.45 70 1 D P-1 Kit.area Wall Plaster Intact Beige POS 1.61 t 0.58 71 1 D P-1 Kit. area Ceiling Drywall Intact White NEG -0.22 f 0.73 72 1 C P-1 Bath Window Wood Sill Intact Brown NEG 0.04 f 0.09 73 1 C P-1 Bath Window Wood Casing Intact Brown INCOM 0.08 t 0.14 74 1 C P-I Bath Window Wood Casing Intact Brown NEG 0.06 t 0.15 75 1 A P-1 Bath Door Wood Intact Blue NEG 0.00 t 0.13 76 1 A P-1 Bath Door Wood Jamb Intact Brown NEG 0.00± 0.07 77 1 D P-1 Bath Door Metal Radiator Intact Blue NEG 0.01 t 0.14 78 1 A P-1 Bath Wall Drywall Intact Blue NEG 0.00± 0.07 79 1 B P-1 Bath Wall Rht Plaster Poor Blue POS 2.57 f 1.17 80 1 C P-1 Bath Wall Plaster Poor Blue POS 2.96 t 1.31 81 1 D P-1 Bath Wall Lft Plaster Poor Blue POS 2.02± 0.89 82 1 D P-I Bath Wall Ctr Drywall Intact Blue NEG 0.00± 0.07 83 1 D P-1 Bath Wall Rht Drywall Intact Blue NEG 0.00 t 0.06 84 1 B P-1 Bath Wall Ctr Drywall Intact Blue NEG 0.02 t 0.04 85 1 C P-1 Bath Ceiling Drywall Intact White NEG 0.00 f 0.01 86 1 D P-1 Cubby Window Wood Sill Fair Brown NEG 0.02 f 0.05 87 1 D P-1 Cubby Window Wood Casing Intact Brown NEG 0.12 t 0.10 88 1 A P-1 Cubby Wall Upr Plaster Intact Bone NEG 0.00 t 0.01 89 1 B P-1 Cubby Wall Plaster Intact Bone NEG 0.02± 0.10 90 1 C P-1 Cubby Wall Upr Plaster Intact Bone NEG 0.00± 0.04 91 1 D P-1 Cubby Wall Upr Plaster Intact Bone NEG 0.00 f 0.12 92 1 D P-1 Cubby Ceiling Drywall Intact White NEG -0.32± 0.85 93 1 B P-I Cubby Metal Radiator Intact Grey NEG 0.01 t 0.06 94 1 B P-1 Play Window Rht Wood Sill Intact Brown NEG 0.00 t 0.02 95 1 B P-1 Play Window Rht Wood Casing Intact Brown NEG 0.00 t 0.02 96 1 B P-1 Play Window Rht Wood Sash Intact Brown NEG 0.00 t 0.03 97 I B P-I Play Window Rht Wood Sash Ext Intact White NEG 0.00 t 0.06 98 1 D P-1 Play Window Wood Sash Intact Brown NEG 0.00 t 0.11 99 1 B P-1 Play Door Metal Door Rht Intact Red NEG 0.00 f 0.07 100 1 B P-1 Play Door Wood Casing Intact Brown NEG 0.00 t 0.02 101 1 B P-1 Play Door Wood Jamb Intact White NEG 0.01 t 0.19 102 1 B P-I Play Door Metal Side Lite Lft Intact Red NEG 0.02 t 0.04 103 1 C P-1 Play Door Metal Intact Red NEG 0.02± 0.06 104 1 C P-1 Play Door Wood Jamb Intact Red NEG 0.00 f 0.11 105 1 D P-1 Play Door Metal Intact Red NEG 0.00 f 0.01 106 1 D P-1 Play Door Wood Casing Intact Brown NEG 0.00 t 0.07 107 1 C P-1 Play Metal Radiator Intact Grey NEG 0.01 t 0.20 Site; 27 Spielman Rd,South Windsor,CT 06074 DatPaint Page 317 No Flr Side Room Comp Sub Feat Cond Color Result Pbc±Prec 108 1 A P-1 Play Wall Drywall Intact Bone NEG 0.00 f 0.00 109 1 B P-1 Play Wall Drywall Intact Bone NEG 0.00 f 0.08 110 1 C P-1 Play Wall Drywall Intact Bone NEG -0.72+ 0.96 111 1 D P-1 Play Wall Drywall Intact Bone NEG 0.00 t 0.11 112 1 B P-1 Play Ceiling Drywall Intact White NEG 0.15 f 0.60 113 1 D Rear Room Door Rht Wood Door Rht Fair Yellow NEG 0.00 t 0.11 114 1 D Rear Room Door Rht Wood Door Lft Fair Yellow NEG 0.00 f 0.09 115 1 D Rear Room Door Rht Wood Jamb Intact Yellow NEG 0.02 f 0.17 116 1 A Front Entr. Window Rht Drywall Sill Intact Wallpaper NEG 0.00+ 0.02 117 1 B Front Entr. Door Metal Intact Beige NEG 0.00+ 0.01 118 1 B Front Entr. Door Metal Side Lite Rht Intact Beige NEG 0.13+ 0.23 119 1 B Front Entr. Door Wood Casing Intact Brown NEG 0.00 t 0.09 120 1 C Front Entr. Window Lft Drywall Sill Intact Wallpaper NEG 0.01 + 0.09 121 1 C Front Entr. Door Wood Fair Red POS 17.18 t 8.01 122 1 C Front Entr. Door Wood Fair Red POS 16.99+ 7.48 123 1 C Front Entr. Door Wood .Iamb(1st 3") Intact Wallpaper POS 7.1.5 t 2.38 124 1 C Front Entr. Door Drywall Jamb Intact Wallpaper NEG 0.00 t 0.01 125 1 C Front Entr. Door Wood Threshold Fair Beige POS 1.31 f 0.26 126 1 A Front Entr. Wall Drywall Intact Wallpaper NEG 0.00± 0.09 127 1 B Front Entr. Wall Drywall Intact Wallpaper NEG 0.00+ 0.12 128 1 C Front Entr. Wall Drywall Intact Wallpaper NEG 0.00 t 0.06 129 1 D Front Entr. Wall Drywall Intact Wallpaper NEG 0.00 f 0.11 130 1 C Front Entr. Ceiling Drywall Intact White NEG 0.01 + 0.12 131 B Exterior Door Rht Metal to future entr. Intact Grey NEG 0.03+ 0.08 132 B Exterior Door Rht Metal Side Lite Rht Intact Grey NEG -0.33+ 0.88 133 B Exterior Overhang Rht Wood Column Lft Intact White NEG 0.00 t 0.04 134 B Exterior Stairs Metal Railing Lft Fair Blue NEG 0.08 f 0.13 135 B Exterior Door Metal to basement Intact Grey NEG 0.03+ 0.07 136 B Exterior Door Lft Metal Intact Grey NEG 0.05 t 0.37 137 B Exterior Door Lft Metal Side Lite Rht Intact Grey NEG 0.10 f 0.17 138 B Exterior Overhang Wood Column Lft Intact White NEG 0.00± 0.17 139 B Exterior Overhang Wood Floor Fair Blue NEG 0.04+ 0.02 140 B Exterior Stairs Metal Railing Fair Grey NEG 0.08 t 0.21 141 D Exterior Door Metal Fair Blue NEG 0.05 f 0.23 142 D Exterior Bulkhead Metal Door Fair Grey NEG 0.01 + 0.04 143 D Exterior Bulkhead Metal Frame Fair Grey NEG 0.00 t 0.11 144 D Exterior Stairs Metal Railing Fair Blue NEG 0.02± 0.18 145 D Exterior Stairs Wood Wall Lft Fair Grey NEG 0.00 t 0.13 146 D Exterior Stairs Wood Wall Rht Fair Grey NEG 0.01 f 0.02 147 D Exterior Oil Metal Fill Pipe Poor White NEG 0.06 t 0.31 149 D Exterior Oil Metal Vent Pipe Poor White NEG 0.01 t 0.20 149 A Shed Door Metal Fair Grey NEG 0.01 f 0.10 150 A Exterior Grounds Wood Fence Fair Unpainted NEG 0.00 t 0.14 151 Calibration Surface 1.6+/-0.2 POS 1.60 t 0.29 152 Calibration Buried 1.6+/-0.2 POS 1.54 t 0.37 153 Calibration Buried 1.1+/-0.1 POS 1.14 t 0.26 154 Calibration Buried 1.1+/-0.1 POS 1.12 f 0.26 155 Calibration Buried 0.0+/-0.1 NEG 0.02 t 0.16 Positive Reading Summary Paint Page 1 Connecticut Lead Paint Solutions 1245 Hebron Ave,Glastonbury,CT 06033 860-633-3330 Since1993 Serial#XL309-U4306NR8622 Site: 27 Spielman Rd,South Windsor,CT 06074 Date: 11/17/2007 No Fir Side Room Comp Sub Feat Cond Color Result Pbc t Prec 61 1 D P-1 Kit.area Closet Wood Cleat Fair White POS 1.81 t 0.56 62 1 D P-1 Kit.area Closet Wood Cleat Fair White POS 3.11 t 1.21 63 1 D P-1 Kit.area Closet Plaster Wall Peeling White POS 4.04 t 1.37 69 1 D P-1 Kit.area Wall Plaster Intact Beige POS 1.16 f 0.45 70 1 D P-1 Kit.area Wall Plaster Intact Beige POS 1.611 0.58 79 1 B P-1 Bath Wall Rht Plaster Poor Blue POS 2.57 f 1.17 80 1 C P-1 Bath Wall Plaster Poor Blue POS 2.96 t 1.31 81 1 D P-1 Bath Wall Lft Plaster Poor Blue POS 2.02 f 0.89 121 1 C Front Entr. Door Wood Fair Red POS 17.18± 8.01 122 1 C Front Entr. Door Wood Fair Red POS 16.99 t 7.48 123 1 C Front Entr. Door Wood Jamb(1st 3") Intact Wallpaper POS 7.15 t 2.38 125 1 C Front Entr. Door Wood Threshold Fair Beige POS 1.31 ¢ 0.26 This is a summary of all positive readings determined during the inspection, on both interior and exterior surfaces. It should be assumed that any similar component in the same room or area is also positive for LBP. Assume that walls A and B in the P-1 Kitchen Area are also positive for LBP. ENVIRONMENTAL HAZARDS 4 SERVICES, L.L.C. 9 1 A - 804-275-4788 FAX$04-275-4907 WIPE LEAD ANALYSIS SUMMARY CT Lead Paint Solutions,Inc DATE OF SAMPLING: 17 Nov 2007 CLIENT: DATE OF RECEIPT: 21 Nov 2007 Glastonbury, CT 06033 Hebron Avenue DATE OF ANALYSIS: 21 Nov 2007 Glas DATE OF REPORT: 23 Nov 2007 CLIENT NUMBER: 7-1566 D EHS PROJECT#: 2007-11-2015 PROJECT: 07-0352 CLIENT WIPE TOTAL CONCENTRATION EHS SAMPLE# SAMPLE# AREA ft2 LEAD u u lft2 01 DW-1 1.00 <20 <20 02 DW-2 0.646 <20 <31 03 DW-3 1.00 <20 <20 QUALITY CONTROL DATA 112107W-14 BATCH#: 01-03 INCLUSIVE EHS SAMPLE NUMBERS: 96.8 Recovery Continuing Calibration Verification 10(10.0ppm Pb) 100% Recovery Continuing Calibration Verification 5 (5.00ppm Pb) 91.2%Recovery Laboratory Control Standard 91.8%Recovery Matrix Spike 0.656 RPD Duplicate Relative Percent Difference 20ug Reporting Limit 3.Ou Method Detection Limit PREPARATION METHOD: ASTM E 1979-98M ANALYSIS METHOD: EPA SW846 7420 ANALYST: Aub ey Simonds Reviewed By Authorized Signatory: Michael A.Muelle , H, Lao tory Director Howard Varner, General Ma g r Irma Faszewski,Quality Assurance Coordinator David Xu,MS, Senior Chemist Sample results denoted with a"less than"(<)sign contain less than 20ug total lead,based on a 40ml sample volume. The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description,area,volume etc.,was provided by the client. If the report does not contain the result for a field blank, it is due to the fact that the client did not include a field blank with their samples. EHS sample results do not reflect blank correction. This report shall not be reproduced, except in full, without the written consent of Environmental Hazards Services,L.L.C.California Certification#2319 NY ELAP#11714 LEGEND ug=microgram ppm=parts per million ug/ft2=micrograms per square foot mi=milliliter Pb=lead ft2=s uare fast wi pepb 15.AA220.dot/13MAR2007/REV3/MR/pd —PAGE 01 of 01 --END OF REPORT-- Environmental Hazards Services, LLC 7469 White Pine Road Richmond, Virginia 23237 5 804-275-4788 ,_ .; a z. e CUSTODY FORM :�v ,:,w. CHAIN OF CUS ¢�� , '' (�. y-.S..E:.:.w„`. •. .tie, ` Date: November 19, 2007 Sill to; CT Lead Paint Solution` Company Name: CT Lead Paint Solutions Address: 1245 Hebron Ave. City, State, Zip Glastonbury, CT 06033 E-mail to; Phone: 860-633-3330 andrew@leadtests.com Project Name: Creative Kidz Child Care Dates of Coll 17, 2007 Assessment Tests Project Address: 27 Spielman Rd, South Windsor, CT 06074 Project Number 07-0352 Method Instrument Method Detect Limits TAT Matrix wi e 24 hours Lead in Paint NIOSH 7082M Flame Atomic Absorption 3.0 ug/ p Ghost Wipes Used Lead in Dust Location Sample and substrate Area Lab Sample # Area size/ notes s uare inch Bath #1 DW-1 144.00 Floor, C side vin 1 Path #1 I(, DW-2 93.00 C side, Wind. sill wood Cub b Area DW-3 144.00 or Cside, vin 1 ti Collected Andrew Miller Si ature Date: Nov. 17, 2007 Mailed b Andrew Miller Si ature Date: Nov. 19, 2007 Signature gnature Date: b ENVIRONMENTAL HAZARDS SERVICES, L.L.C. 7469 WHITE PINE ,VA 23237 804-276 4788 FAX 804-276 4907 LEAD IN SOIL ANALYSIS SUMMARY CLIENT: CT Lead Paint Solutions,Inc DATE OF SAMPLING: 17 Nov 2007 1245 Hebron Avenue DATE OF RECEIPT: 21 Nov 2007 Glastonbury, CT 06033 DATE OF ANALYSIS: 21 Nov 2007 DATE OF REPORT: 21 Nov 2007 CLIENT NUMBER: 7-1566 D EHS PROJECT#: 2007-11-2014 PROJECT: 07-0352 EMS CLIENT CONCENTRATION SAMPLE# SAMPLE# PPM (mq/kg) 01 Soil-1 <48 02 Soil-2 <46 QUALITY CONTROL DATA BATCH#: 112107S-2 INCLUSIVE EHS SAMPLE NUMBERS: 01-02 Continuing Calibration Verification 5(5.00ppm Pb) 90.6%Recovery Laboratory Control Standard 83.2%Recovery Matrix Spike 97.2%Recovery Duplicate Relative Percent Difference 7.41 RPD Reporting Limit 20ug Method Detection Limit 2 9ug PREPARATION METHOD: EPA 600/R-93/200 ANALYSIS METHOD: EPA SW846 7420 ANALYST: Aubrey Simonds Reviewed By Authorized Signatory: 1. Michael A. Mueller,MPH, Laboratory Director Howard Varner, General Manager Irma Faszewski, Quality Assurance Coordinator David Xu,MS,Senior Chemist Sample results denoted with a"less than"(<)sign contain less than 20ug total lead,based on a 40ml sample volume. The condition of the samples analyzed was acceptable upon receipt per laboratory protocol unless otherwise noted on this report. Results represent the analysis of samples submitted by the client. Sample location,description, area,volume etc.,was provided by the client. This report shall not be reproduced, except in full, without the written consent of Environmental Hazards Services, L.L.C. California Certification#2319 NY FLAP#11714 LEGEND ug=microgram ppm=parts per million mg/kg=milligrams per kilogram ml=milliliter Pb=lead soi ipb3.dot/AA220AF S/07MAR2006/R EV2/MR/ --PAGE 01 of 01 --END OF REPORT-- Environmental Hazards Services, LLC 7469 White Pine Road Richmond, Virginia 23237 804-275-4788 2007-11-201� '1 °r FHs CHAIN OF CUSTODY FORM Lin Date: November 19, 2007 Bill to; CT Lead Paint Solutions Company Name: CT Lead Paint Solutions Address: 1245 Hebron Ave. City, State, Zip Glastonbury, CT 06033 E-mail to; Phone: 860-633-3330 andrew@leadtests.com Project Name: Creative Kidz Child Care Dates of Collections: Assessment Tests November 17, 2007 Project Address: 27 Spielman Rd, South Windsor, CT 06074 Project Number 07-0352 Matrix Method Instrument mdls TAT Lead in Soil EPA846-7420 Flame Atomic Absorption 20mg/kg 24 hours 20 ppm Lead in Soil Sample # Exterior Area Location Sample Comments Lab notes Soil- 1 Pre-School Playground Area 8 comp. samples Soil- 2 Infant Playground Area 8 com . samples Collected from bare soil Near play equipment Note; lab, please mix soil sample Collected Andrew Miller Signature Date: Nov. 17, 2007 Mailed by Andrew Miller i6ignat4re Date: Nov. 19, 2907 Received 1g, re r Date: 3 � by r C Side P-1 (Play Area) Infant Play Area (rear play area) (new addition about 1988) C B Room Sides D not tested A— P-1 P-1 (Cubby Area) Bath P-1 (Kit. Area) Toddler-3 (b) D Side B Side I cl I Toddler-3 (a) Pre-school Play Area Stairs (not tested) Future Front Entrance A Side I st Floor Creative Kidz Child Care 27 Spielman Rd, South Windsor, CT 06074 HE.-,DER/ �lt.Ct"`•'1ll�tAS4htRY9 SIDING -�- --It= WINDOW SASH -7 P WINDOW CASING ATTIC VENT RAKE BOARD CORNICE UPPER FREEZE BOARD TRIM SASH FASCIA SOFFIT r'OCTERIOR DOOR JAMB BLIND STOPS o DOOR CASE CASING THRESHOLD DOWNSPOUT SHUTTER-/ SKIRT BOARD CORNER BOARD BULK HEAD SKIRT BOARD PIPE MUCLIm CELLAR WINOCYW S1aalGxl FOUNDATION KICK BOARD SASH CASING muNrIm WINDOW ERE) TRIM (CDNJSII� / PART OF SASH} APRON CROWN MOLDING J SILL HEADER UPPER WALL (CONSIDERED O SIDECASING)ED BLIND STOP DOOR CASING! DOOR FRAME CHAIR RAIL PARTING BEAD JAMB WINDOW WELL/TROUGH (BETWEEN INTERIOR& LOWER WALL STORM WINDOW) WINDOWSILL BASPBOARD RAIL CAP WALL NEWEL BRACKETS BASEBOARD POST UPPER FASCIA COLUMN -RIM BEAM TREAD SUPPORTS LOWER RAIL CAP RISER RAIL UPPER RAILID STAIR STRINGER BALUSTERS BALUSTERS LOWER RAIL FLOOR CABINET BASE LOWER TRIM (SKIRT BOARD) WALL LATTICE SHELF LATTICE PRAME SHELF SUPPORT A Not., Swl tj G S�► �� f Co vE7ZE,- ZY- f-+ n - vv-ra�tL. NG v .� t E December 07, 2007 CT Lead Paint Solutions 1245 Hebron Avenue Glastonbury, CT 06033 Attn: Andrew Miller a Please find attached laboratory report(s) for the samples submitted on: November 20, 2007. All pertinent info rmation ormateon for this analyses is located on the report. Should it be necessary to contact us regarding billing or the test results, please have the following r information readily available: s Lab No. : 1107313 Invoice No. 151458 Customer No. 1280 Please contact us if you have any questions. Very truly yours, Stepheh J. Franco Laboratory Director n PH-0547 connecticut _ = STEPHEN 9. ERANCO testinom LaborLitorV Director l - j PHONE 203/634-3731 C' inc. www.ctl-web.com /ctestlab@erols.com WATER SOIL AIR 1 h5 GRACEY AVENUE MERiDEN, CT 064511 Page 1 n Date Samples Received: 11/20/07 Client Name : CT Lead Paint Solutions Report Date : 12/06/07 CTL Lab No. : 1107313 PO/Job No. 27 Spielman Rd. South Windsor, CT RESULTS OF ANALYSIS EPA Method 200.9 Matrix Type : W CTL Sample No.: 21367 Field ID : 18`Draw Kitchen Faucet Parameters MDL Total Lead-m /L 0.005 BDL Date Analyzed 12/03/07 Note: This water meets the requirements for lead content in drinking water based on the State of Connecticut Action Level of 0.015 mg/L. MDL= Method Detection Level BDL=Below Detection Level Matrix Type: W=Water/Aqueous S=Soil/Solid 0=Oil/Hydrocarbon Stephen J.'°Franco Laboratory Director PH-0547 Connecticut Testing Laboratories, Inc. 165 Gracey Avenue/ Meriden, CT 06451 (203) 634-3731 (Fax) 630-1336 Certification CT-PH0547/ MA-CT035 act November 23,2007 ** LABORATORY ANALYSIS REPORT ** Pg l of I Attention: P3059/ANDREW MILLER/CT LEAD PAINT SOLUTIONS Kit#: 4218769 Result: <0.3 pCi/1 Analysis Note Location: 1st Floor Analyzed : 2007-11-23 at 3:00 pm Started : 2007-11-17 at 10:00 azn 27 Spielman Rd Ended : 2007-11-19 at 12:00 pm Windsor, CT 06074 Hours/MST% : 50 hours 6.2% 60OF Kit#: 4218771 Result: < 0.3 pCi/1 Analysis Note : Location: 1 st Floor Analyzed : 2007-11-23 at 3:00 pm Started : 200.7—I 1-17 at 10:00 am27 Spielman Rd Ended : 2007-11-19 at 12:00 pmSouth Windsor, CT 06074 Hours/MST% : 50 hours 5.5% 60°F Air Chek,Inc. 1936 Butler Bridge Rd, Fletcher, NC 28732-8792 Phone:(828)684-0893 Fax:(828)684-8498 This Report is prepared for; Creative Kidz Child Care 27 Spielman Rd South Windsor, CT 06074 Radon Tests Two short-term radon tests was taken at the day care center, one in Toddler 3-b room(kit #4218769) and one in the Infant room(kit#4218771). They were suspended from the ceiling at a height of 4 feet from the floor. The tests ran for over 2 days. The test.results for both canisters were<0.3 pCi/L(Pico Curie per liter of air). The test results were well below the level of concern, which are readings at or higher than 4.0 pCi/L (Pico Curie per liter of air). If you have any questions on this report,please do not hesitate to call. Andrew Miller Inspector December 3, 2007 le /.' � t„�-�l� i Y f �• i fr yf 1 CHAIN OF CUSTODY RECORD —connecti� �} r Lab Tracking#: U 7 ; testing laborator► Client: ff ( Re nested Anal ses Project/PO# \ . ( (signature) Lab Use Field (print) ` ID(please print) RSR Reference Time me Matrix Criteria Notes lose Relinquished By:(Signature) r`f r? Date / Time Received By:(Signature) Date / Time Received By Laborator y:(Signature) Date / Time Relinquished By: (Signature) Date / Time Received By:(Signature) / Date / Time Turn Around Time Relinquished By:(Signature) `1f ��• �r Date / Time Received By: 24 HR ❑ 3 Day'❑ 5 Da(Signature) Date / Time y ❑ Y `Turnaround times less than"5 Days"may be subject to priority fee char es. 48 HR' ❑ 4 Day ❑ 10 Day ❑ Matrices=A-gqueous S-Soil/Solid H-Hydrocarbon(Oil) g CTL will not be held liable for incorrectly filled out Chain of Custody Records. Samples held for 45 days Connecticut Testing Laboratories,.Inc. Y from receipt. 165 Gracey Ave./Meriden,CT 06451 Tel.(203)-634-3731/Fax(<103)630-1336 INORGANIC The IVIt-�,-_!y_ [UU/ I I : I7AIVI CUSTOMER SERVICE.®: RISING STARS N0, 109illing P, 2,d 556 Main Street, P.O. Box 800 Account Number: 7112843 06/19/2007 - 09/18/2007 Hartford, Connecticut 06142.0800 Service Address; 27 SPIELMAN RD Due Date Telephone (860) 278.0127 Invoice Number: 200011839602 10/31/2007 Invoice Date: 10/01/2007 Amount Due Meter Number; 31690969 $ 31.47 Previous Meter Reading 1,997 Current Meter Reading 1,997 Water Use CCF 0 Current Charges: Water Consumption Charge @ $1.960 X 0 CCF 0.00 Water CSC Domestic Charge 12.75 Water NMT Surcharge 18.72 Total Current Charges: $31.47 Billing Summary: Past Due $0.00 Current Charges $31.47 Current Balance: $31.47 Please return this portion with your payrnent. Please bring entire bill when paying in person, Service Address: 27 SPIELMAN RD Make Check Payable to MDC Account Numbed 7112843 Due Date: 10/31/2007 Invoice Number: 2000119$9602 Please Pay this Amount Due: $31,47 Invoice Date: 10/01/2007 10,6 PENALTY ADDED IF NOT PAID BY DUE DATE Pay Online at www.therndc.corn RISING STARS Send Paymenr To: 27SPIELMAN RD The Metropolitan District SOUTH WINDSOR, CT 06074 PO Box 990092 Hartford, CT 06199-0092 00000000031471031200700011106721000007112843300300395958031 �c9�/1 /o'7 December 21, 2007 1 Julie Boscarino Child Care Licensing Specialist State Health Department 410 Capitol Avenue MS#12 DAC Hartford, CT 06134 Dear Julie: This is to notify your office that the lead abatement/corrective action plan dated 12-31- 2007 for Rising Star Child Care, LLC at 27 Spielman Road is apporved by this office. Very truly yours, Robert Deptula, R. S. Environmental Health Officer RD/cm Pev ./tfaCjl)Allen f HOW TO CHANGE A DIAPER 1. GET ORGANIZED • Before you bring the child to the changing area,gather what you need: non-absorbent paper. Fresh diaper,wipes,gloves,change of clothes. • Staff must wash their hands and the child's hands prior to all diaper changing • Put on the disposable gloves 2. AVOID CONTACT WITH SOILED ITEMS AND KEEP A HAND ON THE BABY • Anything that comes in contact with stool or urine is a source of germs • Carry the baby to the table,keeping soiled clothing away from you • Bag the soiled clothing and securely tie the bag to send home 3. CLEAN THE DIAPER AREA • Unfasten the diaper • Use disposable wipes or fresh,wet paper towels to clean diaper area. Remember: clean front to back with a clean wipe each time. Put the soiled wipes in the soiled diaper • Report any skin problems 4. REMOVE THE SOILED DIAPER AND CLEAN SURFACES • Fold the diaper over and secure with tabs • Put diaper in a covered,lined step can which is to emptied at least once daily • Check for spills • Remove the gloves and put into the step can • Wipe your hands 5. PUT ON THE CLEAN DIAPER 6. CLEAN THE BABY'S HANDS • Use soap and water at the sink • Dry hands with a disposable paper towel 7. CLEAN AND DISINFECT THE DIAPERING AREA • Dispose of the table liner • Clean any visible soil from the table - • Disinfect the table with a disinfecting solution • Leave the disinfectant on the table for two minutes,the wipe dry or allow to air dry 8. WASH YOUR HANDS AND RECORD ON DAILY LOG • Use soap and water • Use paper towel to turn off faucet • Record action on daily log ** REMINDER: STAFF AND CHILDREN'S HANDS ARE TO BE WASHED BEFORE AND AFTER DIAPER CHANGING. COVERED GARBAGE CANS ARE TO BE EMPTIED AT LEAST ONCE DAILY. o o 9 S CID o o � o oJ� BANDWASHING POLICY ° ° a 0 Wash your hands properly and frequently_ Use soap and running water Rub your hands vigorously. Wash all surfaces, including backs of hands - wrists between fingers Rinse well. Dry hands with a paper towel. Turn off the water using a paper towel, not your clean hands. HELP CHILDREN LEARN THE PROPER WAY TO WASH THEIR HANDS TOO. r Creative Kidz Child Care, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 November 26, 2007 Re: Creative Kidz Childcare, LLC License# 16012 Dear Julie, I hope you had a wonderful holiday. Enclosed please find the initial draft of our new licensing application. Our new name will be Rising Stars Childcare, LLC as soon as the new license issued. e is I did include most of the attachments. The following is a list of items that are• Attachment 5d (will set up a date when the Local Health De t. receive pending: radon testing) p es lead, water and Attachment 5e (pending test results) • Attachment 1 Od (in the process of completion) • Attachment 11 a (in the process of filling out agreement) • Attachment 13a(in the process of completion) • Attachment 13b (all testing done on 11/16/2007; awaiting results) • Attachment 13e (all testing done on 11/16/2007; awaiting results) Attachment 14a (in the process of completion) • Attachment S3 (in the process of completion) If additional information is needed or if you have any questions, please contact 7529. me at 860-528- Sincerely, Renee C. Welch Director COORDINATING CHECK LIST FOR APPLICATION (PLEASE CHECK EACH BOX OR CHECK N/A IF NOT APPLICABLE) ►ATTACHMENT Fee Enclosed Fee Invoice Form /Avvlication COMMENTS Affidavit Worker's Compensation Insurance Certificate �7141'r`oof of Worker's Compensation Insurance Directions 5a Fire :15b, Building c Zoning ❑5d Local Health-Date Application Sent: ❑5e Building structure constructed before 1979 es E]No If yes,a lead inspection is required Lead inspection to be conducted by the local health department or a private licensed lead inspector F-17 Schedule Va Discipline Pol' y: �s-tive Guide [Redirection mits ervision usee�!T4,e,g�lect Policy Closing Time lan: 2 People [ ime Frame[vJEmergency Contacts Alternate Pi k Up o'ficatio Emergency Plans: dical ire [ rJeather ��c} tion d Supervision P n\Out Group Size do L�aP [ZBathroom RrBP athroom supervision Plan(Correlates with loor Plan) /e Operating Policies: Admission w/Hea,�lth, Record agents,Involvement/Access 6�/D greements with PPare�s [3Menus/Times visional Enrollment Period of chit 06ays/Hour peration(in luding sick,vacaa�ti,o��oliday) r.Medication Policies,if applicable 8f Personnel Policies: ob Description enefits r I2 obation Period Supervision of Staff EW agent Communication Btaff Administratio f Medicationses of Medications age of Medications �.Voc � ecord Keeping arental Responsibilities Responsibilities Iedication Training Certificates a Staff Work Schedule Form b Fingerprint/Background Checks(Submit to the Legal Department) Head Teacher Form or Certificate of Approval []10 Organization Chart 00 0 First Aid Training Certificates Val PR Training Certificate f Plan for Conti uing Education LK%of Total Annual Hours Worke [Attendance at Classes,Seminars,Conferences,etc. EXCE Child Development Licensing,etc. Plan for Consultation [�nnual Policy Review [Availability in Person Annual In-service Ed Program Review [ Availability by Telecommunication eEducation Consultant Form/Cony of Agreement Co v of Agreement/Contract for Physician/Public Health RN [e1c Copv of Agreement/Contract for Dentist 66 d Copy of Agree in for Registered Dietitian tilA 1 e Copv of Agreement/Contract for Social Service Consultan 1 m f Consultant/Head Teacher Data Sheet ❑13a Floor Plan-Indoor 013b Water Supply Attachment: ❑Lead Water Test Results/Date ❑Within Limits(<0.15 ppb) ❑Exceeds Limits ❑Public Water Supply ❑Copv of Bill ❑Bacterial and Chemical Water Test Results/Date ❑On Site Well(In compliance with CT Public Health Code Sections 19-13-1351 and 19-13-13102) ❑Local Health verified with DPH Water/Supplies Section for facilities licensed to serve 25 or more adults and children over 60 days per year ❑Private Well—Facilities serve less than 25 children&adults ❑Other(Please Specify) [ 3c Number of Toilets ildren dults Number of Sinks hildren Adults ❑13d Pet Care Plan ❑Procedures for are&Maintenance ❑Access to Children tJ ❑13e Radon Test Results M 14a Sketch-Outdoor Play Space ePool Approval f4 A Educational Progrdm Plan nfant/Toddler Preschool Clechool Age ❑S4 Indoor Floor Plan for Infant Toddler Nurse's License and RReWe 5a Diapering Plan �' pering Procedure 26posal of Diapers ad washing [Sanitizing Process ❑S5b Cloth Diaper Plan ❑Place in Sealed Container ❑Removing Daily NIA ❑Cleaning&Sanitizing Container Daily T:\Grp&Ctr\Application\G_C_CoordCklist.doe 7/13//05 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH «. Division of Community Based Regulation tAiNLr r Child Day Care Licensing—Fee Invoice Form The licensing fee is due with your application to obtain or renew a child day care license. THE FEE IS NON- REFUNDABLE. Please complete items 1 through 10 of this form. If you have questions,call the licensing office at 1-800-282-6063, 1-800-439-0437 or(860) 509-8045. Make your payment by check or money order payable to: TREASURER-STATE OF CONNECTICUT. Mail this form along with your payment and application to the Department of Public Health at the address on the bottom of this form. 1. Name of Licensee or Applicant: (Legal Operator) 2. Program Name: _i-__J-a!s . (Applicable For Group/enter Only) 3. Program Location Address: S 1 .�C�•t� l ��'s,K. �� i , CT Zip Code Street Address City/Town P 4. Program Phone Number: > - Program Fax Number: 5. License#: Expiration Date: (For Relicensure Only) (For Relicensure Only) 6. Mailing Address(if different): CT Street Address`` City/Town Zip Code 7. Program E-mail Address: IJ 8. Enclosed Check/Money Order: $� Check Date: V. Do Check#: 9. Social Security#: - - or Federal Employer ID #: �- j� 9 � 30�� — (3 digits) (2 digits) (4 digits) (2 digits) (7 digits) 10. Payment is for the following type of license: (check one box below) Child Day Care Center Group Day Care Home Family Day Care Home i (Account-942431) Account#42431) (Account#4243I) V6-month license(new program) ❑ 6-month license(new program) ❑2-year license(new provider) $50.00 $30.00 $20.00 i =2-year (relicensure) 2-year license(relicensure) ❑2-year license(relicensure) 0.00 $200.00 $100.00 Phone: (860) 509-8045, Fax: (860) 509-7541 Telephone Device for the Deaf (860) 509-7191 u 410 Capitol Avenue-MS# 12CBR P.O. Box 340308, Hartford, CT 06134 An Equal Opportunity Employer � + T:\Fam&Ctr\ADnlication\CDC FeeForm.doc 3/22/04 1CLt� Cl Ir�' �� STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Child Day Care Center or Group Day Care Home AFFIDAVIT NOTE: This form must be completed by the Operator or the individual authorized to represent and act on behalf of the Operator. I, C_ W being duly sworn depose and say: Name of Operator(if Operator is an individual)or Legal Representative The name of the child day care center/group is Sfa(S C{ l� (, rA(-e P L-L C— Nametd Child Day Care Center/Group Day Care Home The application is made to conduct is child Pay care center/group da care home at: -1 5 Nel ota MI)Asmr D(pD`I Location Addre s: Street City/Town n State Zip Code The Operator of the above named facility is Q(fJne�_C &) Name of Operator and is a(check one): ❑ Individual/Sole Proprietor ❑ Corporation ❑ Partnership D/lumited Liability Company ❑ Limited Partnership ❑ Limited Liability Partnership If applicable,the individual authorized to act on behalf w ` 6 ` of the operator of the above name facility is: Name of Legal Represe tative I am the Operator and am legally responsible for the operation of said program or I am the Legal Representative and am duly authorized and empowered to act as of this date on behalf of the Operator. My phone number is(� )��- `7 My address is 1 r ( Gf? treet,City/Town,State,Zip Code I have read the Connecticut General Statutes and Regulations of Connecticut State Agencies(Public Health Code)relating to the licensure and operation of a child day care center/group day care home. The information contained in this application is true and indicates compliance with the aforementioned Statutes and Regulations. I will ensure that this program will be operated in compliance with the aforementioned Statutes and Regulations and with any Consent Order executed with the Department of Public Health or any successor agency. I give my permission for a full unannounced inspection of the facility and a comprehensive review of the program and staffing plans for the child day care center/group day care home by the State Department of Public Health, and the local health department for the purposes within their authority,at any time throughout the period for which the license is issued. I understand that the Department of Public Health must be immediately notified of any change in the plan of operation affecting any condition contained in the application upon which the license is renewed and of any change in the legal representative. I understand that the license is time limited, is subject to review, and that renewal is necessary for continued operation of the child day care center/group day care home. Any false statements made herein are punishab in accordance with Section 53a-157b. Signature of Operator or Legal Representative Subscribed and sworn to before me on the—_day of O y Ej,L.6� Day Month Year My Commission Exp,Naar.31,2011 . ��natureommissio r of superior court or other proper official as noted in Connecticut General Statute Section 1-24 T:\Grp&Ctr\Application\G C_Affdavit.doc 121205 NORTH AMERICAN SPECIALTY INSURANCE COMPANY WORKERS COMPENSATION EMPLOYERS LIABILITY INSURANCE POLICY Domiciliary office:(800)542-9200 A Stock Insurance Company Policy Period 650 Elm Street;Manchester:NH 03101-2524 Policy Number From To Administrative Office: P.O. Box 50457;Sarasota, FI 34232-0303 WCA 0027234 10/30/2007 10/30/2008 12:01 A.M.Standard Time at the described location Transaction POLICY DECLARATION 1. Named Insured and Address Agent RISING STAR CHILD CARE LLC GE COMMERCIAL INS APPALACHIAN 27 SPIELMAN RD U/W'S WORKER'S COMP .PROGRAM SOUTH WINDSOR CT 06074-4151 800 OAK RIDGE TPKE STE A-1000 OAK RIDGE TN 37830-0000 Telephone: 888-376-9633 0900009 Carrier# FEIN# Risk ID# Entity of Insured ---J 24147 261194802 LTD LIAB CO Additional Locations: 2.The Policy Period is from 10/30/2007 tO 10/30/200812:01 a.m. Standard Time at the Insured's mailing address. 3.A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here:CT B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1oo,000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WEST VIRGINIA, WYOMING, STATES DESIGNATED IN ITEM 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $514 Total Estimated Annual Premium $2,291 Expense Constant $200 Assessments and Taxes Premium Discount Deposit Premium $2,291 This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; El Semiannual; ❑ Quarterly;❑ Monthlyy:- Countersigned this Day of p' �.Aufi'orized Representative Issued Date: 11/01/2007 Issuing Office Sarasota,FL 00 SP001407 Ed.(02-01) Page I of 4 WC000001A (05-88) INSURED COPY WORKERS COMPENSATION EMPLOYERS LIABILITY NORTH AMERICAN SPECIALTY INSURANCE COMPANY INSURANCE POLICY Policy Number: WCA 0027234 Named Insured: RISING STAR CHILD CARE LLC Agent: GE COMMERCIAL IN APPALACHIAN 0900009 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Premium Basis Rate Per Estimated Total Est. Annual $100 Of Annual Code Remuneration Remuneration Premium No. Classification Description Connecticut Unit 00001 128000 1,920 8869 CHILD DAY CARE CENTER-PROF EMPLOYEES & CLERICAL,SALESPERSONS 150,000 . $ 1,920 Unit Total 2,180 0.03500 76 2ND IN 2ND INJURY FUND PREMIUM SURCHARGE 1,920 0.01800 3' CM ASM CT W/C COMMISSION ASSESSMENT 9741 DOMESTIC TERRORISM, EARTHQUAKE AND INDUSTRIAL ACCIDENTS 150,000 0.01000 15 150,000 0.03000 45 9740 FOREIGN TERRORISM 200 0900 EXPENSE CONSTANT $ 2,291 State Total $ 2,291 Policy Total Issued Date: 13 /01./2007 00 SP001405 Ed.(02-01) wcssasol (oz•o1) INSURED COPY Page 2 0 4 &V nlarl�� STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH APPLICATION FOR INITIAL LICENSE CHILD DAY CARE CENTER OR GROUP DAY CARE HOME Complete original application, answering all items as they apply to your program. Please submit: original application to your Day Care Licensing Specialist ❑ Please keep: one complete copy on file at licensed premise ❑ 1. Name of Program: +ct 1 ( 13 Program Location Address 5 ►► ,co a++ Phone: (&Q) (Number&Street) Town/City/State: JDU+�n V� �1 D� CT Zip Code: `-f Mailing Address: (if different,i.e.,RFD or P.O.Box,or central office) Directions for reaching program from Hartford (include street names, landmarks and entrance to program space.) (Attachment#1) • Was the building/structure in which you will be providing child care constructed before 1979? [ Yes ❑No (if yes, please refer to question#5e) 2. OPERATOR: Operator's Mailing Address: (0 ,,�n I QI� I� Business Phone: S �S Town/City/State: C-F Zip Code: 3. DIRECTOR: R2ncc C Home Address: t9 s n i o S 1 C. LC zKe- Home Phone: Town/City/State: Ell 1/\� Zip Code: 0(p() ,1 q 4. HEAD TEACHER: `��i I G� ��e,KLck (designated for site) kca jllall b^ 2 5. LOCAL APPROVALS: a. LOCAL FIRE approval(Attachment#5a) b. LOCAL BUILDING approval (Attachment#5b) C. ZONING approval(Attachment#5c) d. DATE you sent copy of application to LOCAL HEALTH DEPARTMENT e. LOCAL HEALTH Approval(Environmental Inspection Report) A lead inspection is required for buildings constructed before 1979. If a lead inspection is required the local health department/private licensed lead inspector's Lead Inspection Report must be submitted. If lead-based paint or lead hazards are not identified, no additional documents are required to be submitted. If lead-based paint or lead hazards are identified, any of the following documents that are generated based upon the inspection results must be submitted: (a) Plan of Abatement/Correction, (b) Letter of Compliance from local health department,(c)the Management Plan. 6. ENROLLMENT: Requested licensed capacity: 4 Ages of children you will accept: t O tAx, Ks _ O -9 Pam.i S SERVICES PROVIDED: Infant/Toddler 6 weeks-3 years Preschool 3-5 years ❑ Kindergarten 5-6 years School Age 5 years&over (Attending Kindergarten at your facility) (Attending Elementary School) ❑ Night Care 7. OPERATIONS OF CENTEWHOME: (Indicate time open each day) Monday TQ0aM "&:QQ&Wuesday_7 b0r�m` Lp f MWednesday `1 t a al - 66,6M Thursday] : 00 am - �:0010 yl Friday� OQann- o:17hnw,Saturday 1.�p�ej- Sunday C, Use (i.e.,Mon. 9 AM-12 PM; Tues. 10 AM-12 PM; Wed. 2-4 PM) Months Center/Home Operates: de o e")ber to , fp "� � (i.e., September to June) Days/Weeks program is scheduled to be CLOSED : (i.e.,holidays, in-service,vacations). (Attachment#7) 8. ADMINISTRATION: Attach copies of the following policies,procedures and forms: a. Discipline policy including accepted and prohibited discipline methods. (Attachment#8a) b. Plan for the care of the child not picked up at closing time. (Attachment#8b) Department of Public Safety Division of Fire, Emergency& Building Services Office of State Fire Marshal b STATE OF CONNECTICUT On 5-1-06, the South Windsor Office of the Fire Marshal conducted an inspection of Creative Kidz Child Care, LLC located at 27 Spielman Rd. in the City/Town of South Windsor to determine the degree of compliance with the fire safety requirements of Connecticut General Statutes Chapter 541 as authorized by Section 29-305 of the statutes. This facility was evaluated as a existing Day Care as classified by the CONNECTICUT FIRE SAFETY CODE. As a result-of this inspection, the following conditions were found: ® I. At the time of inspection, no code violations were identified, Certificate of approval recommended. ❑ I1. At the time of inspection, conditions were discovered to be contrary to the minimum requirements of these codes. An acceptable plan of correction was submitted. (See attached information) Certificate of approval recommended. ❑ III. At the time of inspection, conditions were discovered to be contrary to minimum requirements of these codes. No approved plan of correction was submitted. (See attached information) Certificate of approval NOT recommended. ❑ IV. Based on the extreme hazard to public safety discovered at the time of inspection, this office is currently seeking an injunction from the court through our Town/City Attorney for the purpose of closing or restricting usage of this facility by the public. (See attached information) Certificate of approval NOT recommended. -� Sept 14, 2007 WSJ er Summers, Fire Marshal Date City or Town: South Windsor ***FACILITY DUE FOR ANNUAL INSPECTION IN NO VEMBER ** I NOV-09-2007 11:J1 - - APPROVAL FOR CHILD DAY CARE [ Town Zoning Department FT Town Building Department Town.Fire Marshal. Director of Health AN ❑ .Fnspection : ❑ ' Architectural Review Administrative Review/Inspection Not Required HAS BEEN COMPLETED ON: (� Child Day Care Center ❑ Group Day Care Home LOCATED AT'. G eCth\�C C CalI cCi�C, .. (Street Address) (rown) (State) (.dip) 1S CONSTRUCTED IN ACCORDANCE WITH APROPR�IATE USE GROUPS AND; 0 The State Building Codes in effect at the time of construction ❑ Chapter 9, Article X1 of the Fire Safety Code j Town Zoning Regplations ❑ Health Ordinances ❑ PRELIMINARY APPROVAL IS GRANTED ( ( FIN L APPROVAL IS GRANTED Signed: tiC Title: 7n l r)(__ Y EoLcp Town: Scx '1 V. ')r)d Sbr'... Date: s:\Division\Licensum\Grp&ctr\Fieid Forms\Appraval Form-Local Hcahh.doc 6126102 TOTAL P.01 "-q�A Olen DISCIPLINE POLICY We recognize the fact that children need positive guidance throughout their development. The importance of using positive re-enforcement and redirection as a form of discipline is imperative to teach children how to transfer their negative behavior into a more constructive activity. The staff will not use abusive, neglectful, corporal,humiliating or frightening punishment. A child shall not be physically restrained unless it is necessary to protect the safety of the child or the other children under the care of the center. The only form of discipline practiced by the staff will be an attempt at redirection through communication or if necessary a brief time-out period not to exceed one minute per year of age. Parents will be informed of any action. A copy of the abuse and neglect policy is posted in the center. The staff is educated in their responsibility as a mandated reporter and the legal obligations of their position. The staff is properly supervised to assure compliance with the discipline policy. The staff will act as a positive role model to the children in their care. Proper language usage will be practiced as well as common courtesy. The children will be introduced to manners through the model of the teachers and staff. Tone and presentation will be appropriate and in compliance with the policies of the company. We recognize the importance of clearly defined limits to children. The staff will articulate and reinforce those behaviors or conduct which is inappropriate as well as those, which are appropriate. The use of adult vulgarity will not be accepted. Physical contact against the staff, teachers, or parents will not be accepted. Excessive aggressive behavior will be monitored and if determined to be a threat to the safety of the child or other children, will not be accepted. A disenrollment policy is on file regarding the action to be taken should it become necessary to discontinue enrollment. The staff will maintain the state mandated ratios at all times per company policy. The staff will receive continuing education on any subject, which is of importance to the performance of their jobs or the understanding of the needs of the children in our care. The staff will be encouraged to recognize and acknowledge the need for assistance and will ask the supervising staff member or director for insight and help. The supervising staff member will assist in any and all areas where the staff may require a helping hand. The command chain is evident regarding the decisions of the center. I have read and understand the discipline policy. I have been given the opportunity to ask questions and obtain verification of intent. Staff Signature Date Aftac,lomeo-r 1fo, ABUSE AND NEGLECT POLICY By Connecticut state law, all childcare providers are mandated reporters of suspected child abuse and neglect. We are committed to preserving the safety and well being of the children who attend our centers as well as the integrity of each child's family. We fully comply with the state regulations and requirements regarding the reporting of child abuse, neglect or the risk of either. The company policy regarding abuse and neglect is posted in each center for parental information and review. Definitions: [mandated reporter: individuals who are required to report,or cause a report to be made,when in their professional capacity,they have reasonable cause to suspect or believe that a child under the age of 18 has been abused,neglected or is placed in imminent risk of serious harm by a person responsible for the child's health,welfare or care,or by a person given access to the child by a responsible person. (Connecticut General Statutes 17a-101 a) Child Abuse: a child who has a non-accidental physical injury inflicted upon him or has injuries which are at variance with the history given of them,or is in a condition which is the result of maltreatment, such as but not limited to,malnutrition,sexual molestation or exploitation,deprivation of necessities,emotionai maltreatment or cruel punishment.(CGS 46b-120) Physical Abuse: The injury of a child by shaking,beating,burning or similar acts. Sexual Abuse: Engaging in sexual behavior with a child or allowing sexual exploitation of a child to occur Emotional Abuse: Excessive belittling,teasing or berating which impairs a child's psychological growth Neglect where a child has been abandoned,is being denied proper care and attention physically,emotionally,or morally,or is being permitted to live under conditions,circumstances or associations injurious to his well-being Child at risk: placing a child in danger of abuse or neglect Should the center or center personnel have evidence that a physical injury has occurred,the center will take the necessary steps to assure that medical attention and or treatment is given to the child. The center staff is qualified to offer initial first aid and to obtain medical assistance if necessary to assure the well being of the child in question. HOW TO REPORT Mandated reporters must report orally to DCF or a law enforcement agency within 12 hours of suspecting that a child has been abused or neglected. The telephone number is posted in the center and is 1-800-842- 2288. reporters may request anonymity to protect their privacy from the family,but DCF is required to tape record all reports made to the hotline. A written report(DCF 136)must be submitted within 48 hours. A copy of the written report must be given to the facility director. A copy of the written report must be given to the executive head of the Department of Public Health as well as to the center director. Immunity from civil or criminal liability is granted to people who make required reports in good faith. Employers may not discharge,discriminate or retaliate against an employee for making a good faith report or testifying in an abuse or neglect proceeding. however, failure to report as required by law could result in fines. Mandated reporters could also be sued for damages if further injury is caused to a child because they did not act. If DCF suspects that the reporter knowingly made a false report,his or her identity shall be disclosed to the appropriate law enforcement agency and to the alleged perpetrator of the incident. 2e cIlaIl b-� Information needed: * name and address of the child, parents,or responsible caregiver * child's age and gender * nature and extent of injury,maltreatment or neglect * approximate date and time the injury,maltreatment or neglect occurred information about previous injuries,maltreatment or neglect came to be known name of the person suspected to have caused the injury,maltreatment or neglect * other information the reporter believes would be helpful * action taken to treat or help the child INTERNAL INVESTIGATION PROCEDURE All staff members shall be educated on the issues and laws associated with abuse,neglect, child at risk and the reporting procedures of the mandated reporter status. When a staff member suspects a child is being abused,neglected or is"at risk",the staff should immediately inform the director,assistant director,nurse consultant or"someone else in charge"within the setting unless such person is alleged perpetrator. The staff member may determine to call authorities or not to call authorities based upon their understanding of the regulations as they relate to their legal obligations associated with the above described status of mandated reporter. The staff must document in writing the information or situation,which as led to concern and said documentation shall be forwarded to the appropriate agencies as required and directed above. The center documentation will remain part of the child's file. The director will review the information provided and immediately begin an internal investigation which shall include but not be limited to the questioning of any staff members who may have information or support for the allegations. BY STAFF If a staff member is suspected of abuse,neglect or placing a child at risk,the staff member will be suspended immediately without pay pending the completion of the internal investigation and/or the DCp investigation. Director discretion may be executed based upon the findings of the internal investigation with regards to suspension. Should the staff member be found in violation,immediate termination will result. Whenever possible and when it will not place the child in a position of further risk,the parents/guardians of the child for whom the report is being filed should be notified of the concerns and the necessity of the report. It should be clearly understood that the law requires a report to be filed. It should also be understood that the investigation would be conducted to the satisfaction of the state agencies per their guidelines. All staff members will be educated in the mandated reporters status and the legal implications of such. Continuing education will be provided for all staff in an effort to maintain and encourage the responsibility of such status. Utilization of the center nurse consultant and social service consultant as well as available state agency personnel will assure staff knowledge of center policy and procedure in addition to the moral and legal responsibilities of protecting the children in our care. I have read and understand the Abuse and Neglect Policy of Joni's Child Care and have had an opportunity to discuss the policy and the enforcement of such. Signature Date Attachment 8b Closing Time Plan Rising Stars Childcare closes at exactly 6:00pm Monday through Friday. At closing there are always 2 staff members present regardless of the amount of children in attendance. Should a child not get picked up on time the following policy is put into effect: While one staff member supervises the child, the other staff member will call each parent. If they are unable to contact the primary caregivers, the staff member will then try to reach each emergency contact person that the parent listed on the Registration Paperwork. The owners will also be contacted. Once all parties are contacted, if there is no answer, we will wait up to 45 minutes before contacting the South Windsor Police Department. 3 C. Emergency plans which include medical, fire, weather and evacuation policies and procedures. These plans should include detailed information explaining how each type of emergency would be handled by the program. (Attachment#8c) d. Supervision of children: This plan shall include information on how the program will maintain ratios, group size, supervision of all areas inside and outside throughout the day including naptime and bathroom areas. (Attachment#8d) e. Operating policies which include information on agreements with parents, parental involvement, medication policies, food service, enrollmentldisenrollment, operating schedule and access to facility. (Attachment#8e) f. Personnel policies which include information on job descriptions for each staff position, employee benefits, staff supervision,probationary period, parent communication. (Attachment#8f) g. Administration of medications: (Required only if program administers medication.) Develop a written plan that includes the types of medications to be administered, parental and staff responsibilities,proper storage of medications and record keeping. (Attachment#8g) 9. RECORD KEEPING: The operator is responsible for maintaining records for each child enrolled in the program. Please be sure the forms you use contain ALL of the required information outlined in the regulations: • Enrollment form • Emergency Medical permission • Permission for responsible adult(other than parent)to remove child from program • Permission for field trips-any activity away from premise(i.e.,walks) • Permission for use of transportation services(if provided) Is transportation provided? ❑Yes VN 10. STAFF- (paid or volunteer): Attach copies of the following: a. List name, date of birth, position, work schedule, date of employment for each employee, including substitutes(use enclosed staff work schedule form.) (Attachment#10a) b. Important: Background Check Fingerprint Cards (To be returned to the Legal Department @ the Department of Public Health, Legal Office, 410 Capital Avenue. MS#12 LEG, P. O. Box 340308,Hartford, CT 06134-0308.) C. Head Teacher: (Use enclosed required experience form.) Supply evidence of required supervised experience and education or attach a copy of Head Teacher Approval. (Attachment #10c) Attachment Sc Medical - In an event of an emergency, the Center will call 911 for assistance. Parents will be notified immediately regarding incident. Staff will be certified in CPR and First Aid to handle emergencies as they arise. The first aid kit will be on hand for Center use. If a child needs to be transported by car or ambulance, a staff member will accompany the child until a parent arrives. A substitute staff member will be called in to the Childcare Center to take that staff person's place. Fire - Fire drills will be held on a regular basis. Instructions for exiting the building will be posted in the front and back inside the building. When the fire alarm goes off, each staff member will take their sign-in sheet with them and escort their group to a designated meeting area in the front or back of the Center. The children will line up in their group at their assigned meeting place and the staff member will conduct a roll call. The Director or Teacher in charge shall check all classrooms and bathrooms and closet for any children still in the building and escort them to their proper group. The designated area to be used will be determined by the location of the fire and the children will be brought out the exit farthest from the fire. Staff will be instructed to proper procedures in case of fire. We will keep a log for regular fire drills as we have them. Weather - In the event of bad weather, late openings or closing will be announced on WDRC radio. Parents will be notified of an early closing during the day. In the event of an emergency evacuation, the children will be taken to Bearings & Co. which is on Burnham St. All children and staff will meet in the parking lot to ensure that everyone is present and accounted for and then everyone will walk as a group to Bearings & Co. The children can be taken there under supervision. They have a basement there where the children would be safe. The parents would be notified immediately. Evacuation— In the event that the children need to be evacuated from the childcare facility, they will be walked to Bearings & Co., which is located on Burnham St. All children and staff will meet in the front parking lot to ensure that everyone is present and accounted for and then everyone will walk as a group to Bearings& Co. All parents would be notified immediately. Attachment 8d Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Supervision Policy The staff of Rising Stars Childcare will at all times maintain the child-to-staff ratios as stated in the State of Connecticut regulations. • Children ages three years and older will have at least 1 teacher per each 10 children (or portion of) at all times including, but not limited to, classroom programming, outdoor play, nap time, and any walks or field trips. Group size will not exceed 20 children with a minimum of 2 teachers. • Children under the age of three years will be supervised by at least 1 teacher per each 4 children at all times,including but not limited to,classroom programming, outdoor play, nap time, and any walks. The group size will not exceed 8 children with a minimum of 2 teachers. • Bathroom supervision will be in accordance with these ratios and guidelines. If assistance is needed in changing a child,the floor manager should be notified and asked to assist during this time. • Naptime supervision will be in accordance with the policy listed above and with state guidelines. Children will remain in ear and eye contact at all times. • Outdoor supervision will be in accordance with the above mentioned ratios. Staff will circulate throughout the playground in order to properly supervise outdoor activities. Staff will not congregate and/or engage in lengthy conversation. • Teachers must make regular attendance counts. Children must be counted before leaving the classroom, before entering any group area, before leaving any group area and at any staff change. Classroom clipboards must be present in all areas with an accurate list of children present. Supervision begins when a staff member is present within the center or work area. A child is considered present for attendance and supervision purposes upon entering program space and being received by a staff member. The child remains present until being presented by a staff member to an appropriate adult. Supervision is not just maintaining ratios and being a "body" in a classroom! • Teachers must remain awake and alert when present in the center. • Teachers must be present in programming space when children are present. • Teachers must be actively involved with the children at all times. • During required one-on-one care, i.e.,diapering,hand-washing etc.,the teacher must maintain both verbal and visual contact with the other children in the classroom. • Teachers must communicate with partners and management about supervision questions and issues as they arise to promote quick and effective problem solving. I have received and read a copy of the Supervision Policy. I have had the opportunity to ask questions. I understand the policy and agree to abide by it. Staff Signature Date Supervisor Signature Date Attachment 8e Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Operating Policy Days and Hours of Operation Rising Stars Childcare is open Monday through Friday from 7:00a.m to 6:00p.m.,year round. We are closed for the following major holidays; New Year's Day, Memorial Day, Independence Day, Labor Day,Thanksgiving Day,the day after and Christmas Day. If there are going to be any changes in holiday closings, Rising Stars Childcare, LLC will give parents and Staff at least 60 days notice. Admission A$50 registration fee is due upon registration. Tuition payments are to be made weekly and are due the Friday before the week of care. At the time of enrollment we require the following: • An updated physical form, signed and dated by their pediatrician. Infants must bring in copies of all of their recent immunizations. All children's physicals must be updated annually. • Our registration packet completed and signed including accurate emergency contact numbers. Any changes in address, phone number,employment,etc., must be given to the Director in writing. Agreement with Parents 1. Please call and let a teacher know if your child is going to be absent for any reason. 2. An adult must accompany your child to and from their classroom every day. 3. Your child will have their own cubby space for belongings. Please leave at least 2 spare outfits(weather and size appropriate) in your child's cubby. 4. Parents must supply diapers,wipes,a bottle for all feedings, bay food,formula, etc. (if your child is 1 year or younger,the parent should supply all dietary needs. As the child is able to eat solids and enjoy whole milk,the center does supply 2 snacks per day plus milk and juice.) 5. All items brought in should be labeled including food and bottles. 6. Toys are not to be brought in from home. There is no need to bring in personal items because we provide all toys and daily activities. 7. Parents are to supply sheets and blankets for porta-cribs or cots. Please have a "snug-fitting" spare, labeled sheet in your child's cubby. 8. In case of inclement weather,please watch WFSB-TV Channel 3 Early Morning Network Storm Closing System for closings or delays. Meals or Snacks Parents supply all meals. The center will provide morning and afternoon snack as well as Milk and 100%fruit juice throughout the day. Weekly snack schedules are posted in a conspicuous place. Parent Involvement Rising Stars Childcare has an open door policy. Parents are encouraged to visit their children whenever possible. k" c 113d10--7 �e calf�nu.er.� Access to Program and Facility The center plans for periodic educational and fun field trips. Parents will always receive a permission slip for each field trip. The child can not attend the trip without the signed permission. Parent volunteers are more than welcome. Provisional Enrollment Period There is no provisional enrollment period. Withdrawal of Children Parents must give at least two weeks notice when withdrawing their child from the center. All tuition due through the two weeks remains due. Medication Policies The Center will only administer non-prescription topical medications, diapering and teething ointments. All ointments and topical medications must be brought in their original containers. Proper forms will be given out upon enrolling and must be filled out by the parents. Attachment 8f Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Personnel Policy Please see Attachments 8fa—8fd for Job descriptions including: Director,Assistant Director, Head Teacher and Teacher Employee Benefits All Full Time employees who consistently work 35 or more hours per week,will receive vacation or holiday pay for the following,after successfully completing their 90-day probationary period: New Year's Day Memorial Day independence Day Labor Day Thanksgiving The Day after Thanksgiving Christmas Day You must work the day before and the day after a holiday in order to be paid for any holiday. Supervision of Staff The"Chain of Command"within the center is as follows: All teachers report to the Assistant Director. The Assistant Director reports directly to the center Director/Owner. The Head Teacher is responsible for the curriculum planning and implementation. Issus regarding this area of expertise should be directed to the Head Teacher. The Director will assure that the staff members are properly supervised and the center is operating in accordance with company policy. Probationary Period All employees are subject to a ninety(90)day orientation/probation period. This introductory period is designed to determine your skill,ability, attendance and willingness to do a good job. The introductory period is an important test of your qualifications and your ability to perform the duties assigned to you. At the end of this time,the Director may: • Recommend continued employment • Extend orientation time • Terminate employment Communication with Parents Staff will be accurate and thorough with regards to record keeping. All information regarding daily progress, interest,needs,will be presented in a positive manner consistent with center policy. It is the responsibility of the teacher to report to the Assistant Director, Head Teacher or Director any specific instances or concerns noted. The center administration will contact the parents/guardians with regards to the information provided and may offer insight or options to the parents. The staff will at no time interfere with the parental rights. All parental decisions will be honored with the only exception being those that may appear to pose a threat to the safety and well being of the child or other children in the care of the center. At no time will staff release information regarding any child in attendance at the center. Such information is private and must remain confidential. violation of center, child or family privacy is grounds for immediate termination. /At tcLC�k le4 ROL TITLE DIRECTOR SUPERVISOR OWNERS RESPONSIBILITIES The Director is responsible for the overall operation of the childcare center including curriculum development and implementation,staff' management,financial goals and accountability and meeting client needs. QUALIFICATIONS ® Minimum of a Bachelors Degree in Early Childhood or related field ® Minimum of 5(5)years experience in a childcare setting ® Thorough knowledge of State of Connecticut regulations ® Knowledge of State Assistance Programs ® Knowledge and acceptance of DCF Mandated Reporter requirements ® CPR and First Aid certification or willingness to obtain ® Knowledge of financial accounting procedures ® Excellent written and verbal communication skills • Commitment to excellence RESPONSIBILITIES Oversight of the daily operation of the childcare center to assure compliance with all State of Connecticut guidelines. ® Prepare and execute the daily/monthly/yearly financial objectives ® Execute all administrative duties as outlined by company policy W Assure curriculum presentation in accordance to company policy ® Assure company philosophy presentation ® Assure health and safety of center ® Cooperate with all state agencies regarding regulations m Represent the center professionally at all times ® Communicate needs and issues to company owners ® All other duties as outlined by owners I have read and understand the above outlined information and agree to abide by it. Signature Date Date Signature /-�fita,c,��n1�✓tt �-1' t� TITLE ASSISTANT DIRECTOR SI�PE RV ISOR DIRECTOR UPERV1SI R ITIES The Assistant Director works closely with the director in all aspects of center operations,including staff and curriculum development and management,collections and accounting,family relations and the maintenance of State of Connecticut regulations. The assistant director is responsible for the oversight of the center should the director be unavailable. QUALIFICATIONS o Minimum of an Associates Degree in Early Childhood Education or relate field ® 5+years experience in a childcare setting ® Thorough knowledge of State of Connecticut regulations Willingness to learn and perform administrative and regulatory duties 0 CPR and First Aid certification or willingness to obtain ® Excellent written slid verbal communication skills ® Commitment to excellence RESPONSIBILITIES ® Supervise the childcare center to assure compliance with all state regulations. ® Conduct weekly in-services to center staff ® Supervise and instruct staff in daily classroom management and curriculum implementation. ® Manage ratios and staffing to ensure efficient classroom management and maintain payroll goals ® Manage payment accounts and provide necessary collections ® Mediate staff and family issues when necessary ® Assume Head Teacher responsibilities in absence on Head Teacher • Assume Director responsibilities in absence of Director. ® All other duties as instructed by director I have read and understand the above outlined responsibilities and agree to abide by them. Signature Date Date Supervisor Eck)-) TITLE HEAD TEACHER SUPERVISOR ASSISTANT DIRECTOR DIRECTOR SUMMARY In addition to classroom teaching responsibilities,the head teacher is responsible for the oversight of all lesson planning,planning implementation and staff education with regards to developmentally appropriate practice including in-servicing and follow through. The Head Teacher assumes supervisory responsibility in the absence of the Assistant Director and Director. QUALIFICATIONS ® State of Connecticut certification as Head Teacher ® Well versed in child development and age appropriate curriculums ® Excellent written and verbal communication skills • 2+years classroom teaching experience in varied age groups ® CPR and First Aid certification or willingness to obtain ® Commitment to excellence Responsibilities ® All classroom teaching responsibilities • Prepare and present an appropriate in-service at Ieast once weekly ® Review weekly lesson plans and provide appropriate feedback ® Ensure thorough implementation of lesson plans ® Communicate directly with supervisors regarding staff questions,concerns and needs. ® Assume supervisory responsibilities in absence of Director andior Assistant Director. ® Fully comply with State continuing education requirements. ® All other duties as determined by superiors. I have read and understand this job description. I have had the opportunity to discuss the requirements of this position with my supervisor and to ask questions. Employee � Date Supervisor Date TITLE: TEACHER SUPERVISOR: HEAD TEACHER, ASSISTANT DIRECTOR.,DIRECTOR. AND OWNER SUMMARY: As the primary contact staff-,the teacher is responsible for providing a safe,clean,healthy,nurturing environment for the children of the center. The teacher is responsible for maintaining the educational curriculum and assisting in the physical and cognitive development of the child. QUALIFICATIONS: • l&years of age or older ® CPR and First Aid certification or the willingness to obtain such ® Ability to lift/push/pull 50 pounds safely on a daily basis ® Good written and verbal communication skills ® Desire to care for children and an interest in assisting in their development ® Commitment to excellence RESPONSl331L1TIES: ® Prepare and execute lesson plans according to company standards • Personal care of children within the center according to center policy ® Classroom cleanliness and maintenance as scheduled by the center • Daily meal and snack preparation in accordance to menu and standard health/safety procedure ® Accurate and thorough record keeping ® Administer initial first aid when safe and appropriate v Positive and professional interaction with parents and guests ® Timely reporting to work ® Enthusiastically carry out all responsibilities to meet the daily needs ® Present self appropriately al all times according to company dress code ® Maintain a professional attitude and decorum while working or while on center property ® Attend all required continuing education in-services- i°io of hours worked o All duties as requested by director or designee I have read this,job description and reviewed it with my supervisor. I have had the opportunity t o ask any questions. I am aware that any part of this information may be modified as necessary for center operation. Employee signature Date Printed name Supervisor signature Date Attachment 89 Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Administration of Medication Policy Types of Medication Rising Stars Childcare will store and administer prescribed inhalers and epi-pens, non-prescription topical medications and Emergency Oral Medications(i.e., Benadryl)with parent's consent. An authorization form,which must be signed by a doctor and parent is available will be available at the center as needed. Parental Responsibilities Parents are responsible for supplying the childcare with the appropriate information needed to administer medications,such as: The non-prescription topical medication form and the Doctor's order for all epi-pens and inhalers. The forms include information such as: • Child's name, address and birth date • Name of drug • The prescribed dosage • The method of administration • The time to be administered • The side effects • The prescriber's name, number and address All medications must be in their original container and clearly labeled. Parents are also responsibility to update all forms and medications as they become expired. Storage of Medication All medication will be locked in the office cabinet. The epi-pen will be accessible only to the certified teacher's and placed away from the child's reach (not locked). The topical medications must be stored "inaccessible" in the original container and labeled with the child's name and directions for administering. Record Keeping All non-prescription topical forms signed by parents will be located in the child's file. It is the staff's responsibility to properly document and file all paperwork after medication was administered. Included in the documentation are: • The date the medication was administered • The time it was administered • The dose that was administered • The signature of the staff member administering • Any comments Parents will be notified when/if a child has been given any medication. Staff is trained in the administration of medication by our Nurse Consultant. This training is renewed every three years. Epi-pen certification is renewed annually. At no time is an untrained staff allowed to administer medications. (Attachment#10a) Date:�/��/ Q Program Name: I', ( I (.-L _ Phone#: (W ,j,Qj -7 57 jj9 Location Address: 4ZIMajq Town: S)(A* to�License# Mailing Address: sC1i(Yl Town: State: :p Zip Code Prepared By: .�e� C W d Date: f STAFF WORK SCHEDULE FORM DATE OF WORK SCHEDULE STAFF NAME * v BIRTH POSITION DAYS AND HOURS DATE HIRED �. � ' C r " F - (V M Io or _I l L MyF9 - I0115 10-7 CAnDD I 0 _ /D-7 1s ��, �t M-f= _ � PH l9 lb-7 !� 0 0 a� 15 �'�� M- -- PM oI a T-06f6f le M- Fp P OSI ti .F - _T *Place*(an asterisk)by each person's name who has been First Aid Trained within the last 3 years v Place v (a heart)by each person's name who has valid CPR Training �C � n T:\Grp&Ctr\Application\G_C_InitialStaffWorkSch..doc 4/30/03 RETURN TO: J-u L�5 o bo � '�-� C� (6 AeN State of uo nnecticut Department of Public Health issues this approval to: TRICIA MEKUTO tobea DESIGNATED HEAD TEACHER for a CHILD DAY CARE CENTER for "Children Under 3 Years of Age *Children 3-5 Years of Age "School Age Children Having given evidence satisfactory to the Department of Public Health of having met the qualifications in accordance with Section 19a-79-4a of the Regulations of Connecticut State Agencies Date of Approval: 09/05/2007 440 Capitol Avenue, P.O. Box 340308, Hartford, CT 06134-0308 Telephones: 1-800-282-6063, 1-800-439-0437 J. Robert Galvin, M.D., M.P.1I., Commissioner STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH \'0 iu3i4l i>' �Nl Dear Approved Head Teacher: Enclosed you will find your Designated Head Teacher Approval Certificate. This approval certificate is your personal property and is your continued proof that you meet the requirements to be a Head Teacher in Connecticut for the type(s) of program(s) indicated on your approval. We suggest that you make additional copies for your use in the event you seek new employment or if the program where you are currently employed needs a copy. Please be sure to notify the Department of Public Health of any name change or change of address so that we can keep your information accurate and up to date. Sincerely, Department of Public Health Division of Community Based Regulation Child Care Licensing Unit Phone: Telephone Device for the Deaf: (860)509-7191 410 Capitol Avenue-MS# P.O. Box 340308 Hartford,CT 06134 A.Jirrnath,eAction/Art Equal Opportuniq,Ernplorer ��`^� Atneyicari Near, AHA As ociatiort� rTegiol Naw England Region Tcolvf and bve•„ fr autinU -r r p f<r New Friglcand Heal-;-,, earisaver CPR Danielle :µsaran �rai:,fng ,tc New England Health Soltlfions - T , ,9r,1 :.""Ifrs o,nl t.,e Y,.,',.r uualudl h3,5acre,.,PLilly romplWe!t Ian - ob e;twas i!w?evils ev alnaic:1;.:,vrc drnca„vilh t--e currcuilim of;ho AM Richard Antonem `ar"dA,tc.nr GM3 l,CCpa;r. instructor .___.. ---._.... _._.._ ...............__. .._...---...- . ..__ . ._ o�/zQ/ raa7 07/20.03 Holder's gnatum, AHA 4�scxiadon. Neavnglanct Regier� learn and Liver... a,,,,,� _ fart a er- Pediatric First Aid , r Now =nglrandr1C Yit±� is lac:•ns [Danielle t-orari New ar.giand IiF�f,',t n Solt;tons .. .::o plete^tPa 1 °° I I lF r-lwilt t V.cue,.SI.m f, t•T•.vr Richard ?nfoletli f., 1L,.�s,,. U .],.iC:=r r ,-t:•ryr<,'I:. n8trl; 0. 05/01;/zcl01 05/2009 - �itJr••,turn -- 8'fat. ., ::, a.-,:•.-> Atrlericalllteart AHA hi."o6ation, fiEt)itJr: lvt,• : ;fit lt'ir r's(tC: Lem-?;and I rve.. q _ t ,.. sai Pediatric First Aid Q I `i f ozadc3 ain nt r, En;j1� _._.. D,,F rGI r, n �.IU6y c rtulf.tv. 'I,e - __ •� ... ..... „�t r; -1 Q, _I c' 'll EN.,.N hnCStr•ir.IIULt L G.pA ld 1 An IA - -Y1:1:C+f. Orit YP I, u6r,.0 I,tit_Jr: J. 05/2009 American Heart Association® Learn and LiveW Heartsaver CPR C This card certifies that the above individual has successfully completed the national cognitive and skills evaluations in accordance with the curriculum of the AHA for the Heartsaver CPR Program. Adult CPR/Child CPR/Infant CPR Recommended Renewal Date Issue Date AAA) r Ala 117)-7 p Nurse Consultants LLC 259 Silver Street North Granby CT. 06060 1-860-653-5269 License No. R35557 First Aid for Child Car* This Certifies that Teachers ��w'lklL ( Utte.k Cis Has successfully completed the six hour First Aid for Day Care Providers Course in accordance with the Connecticut State Day Care Regulations. Course must be renewed every three years. Robin Young-Cournoyer RR. ------------...--- Recertification due I0-2-09 Signature Date:10-2-06 Attachment 10f Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Plan for Continuing Education All Rising Stars Childcare staff will earn continuing education credit hours annually,which will total at least 1%of their total hours worked. Topics for continuing education may include: • Early Childhood Education • Child Development • Licensing Regulation • Health Issues • Abuse and Neglect • Health Issues • Nutrition • First Aid • CPR • Social Service Attendance at classes,seminars workshops,conferences and forums will be documented in individual staff development records. An assessment of individual development will be developed for each staff member. Attachment 11 Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Plan for Consultation Rising Stars Childcare is required to have an Educational Consultant, Dental Consultant,Social Service Consultant and a Nurse Consultant. The Nurse Consultant will complete a weekly review of all policies, procedure and medical files of staff and children. All other consultants will be available for annual review of our policies and reviewing of our in-service education programs. They will all be available for advice and consultation regarding the program by telecommunication and in person. NURSE CONSULTANTS LLC CONTRACT 259 Silver Street North Granby, CT 06060 1-860-653-5269 1-860-653-9214(Fax) Nconsultan@aol.com As the REGISTERED NURSE CONSULTANTS for the We agree to be available to the owner/director and staff for advice and support regarding the health and safety of the children enrolled at the facility. Consultation will be provided weekly as requested by the director at a rate of $60.00 per hour inclusive of travel time. Responsibilities include: Maintenance of the health consultation log to document visits Maintenance of health records Maintenance of First-Aid Kit Updating Alert List Evaluation of toys and equipment (indoor and outdoor)for safety Observation of diaper-changing area and diaper-changing procedure Observation and provision of health screening for individual children Sharing supplementary material with parents and staff members Communicating with parents and staff members about specific problems Provisions of consultation and acting as a resource person for parents and staff members Provision of in service education Review signs and symptoms to identify child abuse and neglect Review of annual policies Availability by telecommunication for advice regarding health and safety problems ** All billing inquiries will be made directly to Nurse Consultants LLC at 1-860-653-5269, Attention; Robin Young-Cournoyer and no aspect of the agreement shall be discussed with RN assigned to this site, or any other party without prior permission of Nurse Consultants LLC. ** The RN assigned to the above named Child Care facility shall not be hired directly by the above named Child Care facility for six months after the contract has ended ** Any payments received by Nurse Consultants LLC beyond 30 days after the billing date shall be subject to a 10%late fee of the balance outstanding. If payment is not received for services provided by Nurse Consultants LLC by 30 days after the billing date Nursing Consultation services shall cease until such payment is received. Al [C' ch(0 CA� I d b Q��.nt-tom NURSE CONSULTANTS LLC CONTRACT 259 Silver Street North Granby, CT 06060 1-860-5269 1-860-653-9214(Fax) Nconsultantnaol.coan The terms of this agreement are from September 24th, 2007 to September 24th, 2010 and shall automatically be renewed from year to year,thereafter unless terminated by either party with thirty days prior written notice. Sig ature/Owner of Child Care or Director Date Couc" 'el R//V% President Xurse Consultants IIC Date Robin Young-Cournoyer 0�;'d0/2u13 0' 8 FAX Ftislog Stars Child Cara, LLC '27 SpiNlntan Raod South Windsor, Ct 06074 660-528-7529 Aersement for Consult l Senict This is ail agremment beiween Risings Stars Child Care,LLC toad Randal Wing, DDS. The service ig Dental Consultant. Both parties do hereby agrtt that the consultant listed above will be on call for any questions and emergencies that may arise with the shave listed child care, center. It is further agreed.that Randal Wing,DDSv will be listed in the application pith the Department of Health,Sorvicos. The fee per hour of consultation Miall be � � and telephone consultation S., 0 _per ever 15 minutes. Consultant and/or Center may terminate this sgreemont at any time giving notice in whiting to opposite party. ('_onsultant is not responsible for any occurrences whatsoever as a result of consultation. Consultant Name: �� ✓� W t 0 DOS, 0_�s Title: F'� ► r �C -D erow i Address: .� . _ ._� Dr. Randall C. Wing 1050 Sullivan Ave Unit A-1 �._�..... — South Windsor, CT 06074 License#: Consultant Signature: _ � � _��_Date: Direr,of Signature: Q�i( � —Date: TO 39dd JNIM 17VQNb�J W LPCVGP9098 89:ZO LOOZ/ST/iz R181req Mars Chiid Care, LLC 27 Spline a" Rod Sottth 1 IVWsar,'CT 06074 060-UN-7529 Amement for Consultive Services This is an agreement bGtwccn Rising Stars Child Care,LLC and Carol Shil lidgy,PhD, The service is Social Service Consultant. Both parties do hereby agm that the consultant listed above will be on call for any-questions.and emfxgencies that may vase with the above listed child care center. it is further agreed that'Carol Shilliday;PhD,vn'IJ be listed in the application with the Department of Health Services, The fee per hour of consultation shall be SjPv—and rclepbonc consultation 93c—> per ever 15 minutes, Consultant and/or Center may terminate this agreement at any time giving notice in writing to opposite party. Consultant is not responsible for any occurrences whatsoever ass result of consultation. Consultant Name: P Title: Address:_ . f fit.fii.j C-T License--A: Consultant Signtture: r •�. Director Signature; 5 b. WATER SUPPLY: (check one)(Attachment#13b) 12/City/Municipal ❑ Well ❑ Other 1. If water source is City/Municipal, submit copy of most recent bill or other documentation for verification purposes-with program's location address on it. (Attachment#13b) 2. Submit copy of Lead Water Test completed every 2 years for All water supplies. (Attachment#13b) 3. If water source is a well, submit a copy of the Bacterial and Chemical Test every two years. (Attachment#13b) 4. If water source is a well and facility will serve 25 or more adults and children for over 60 days per year, the facility must be in compliance for required water quality testing and well construction for non community public water systems per CT Public Health Code Sections 19-13-B 102 and 19-13-B51, respectively. Information must be verified with DPH Drinking Water Division at(860) 509-7333. • Water Supply Engineer Contact Person: Print Name C. Number of toilets for children: Number of toilets for staff/adults: Number of sinks for children: Number of sinks for staff/adults: d. PETS-If pets are present in the,program submit a written plan for their care and access to children. (Attachment#13d) i v /A e. RADON TESTING: If the program is located in a basement level or ground floor submit copy of radon test. Results must be posted. Testing must be done between the months of November and April. (Attachment#13e) 14. OUTDOOR PLAY SPACE: (attach copies of the following) a. Sketch showing dimensions in FEET. Include information on location of facility, major play equipment, type of surface(s), fencing and storage areas. (Attachment#14a) b. Copy of official swimming pool approval to indicate compliance with Public Health Code, if applicable. 15. EDUCATION PROGRAM: Child Day Care Centers/Group Day Care Homes shall have policies, procedures and activities that meet and enhance the needs of children served. Attach the following information for age groups served: • Educational Program Plan: Describe the educational program plan,which meets and enhances the individual needs of the diverse population of children serviced, including how the program will provide indoor/outdoor physical activities, problem solving experiences, creative arts activities, language learning experiences, self-reliance/self esteem experiences and health education activities. (Attachment#15) 6 The licensing authority (Department of Public Health) must be notified of any change in plan of operation involving facility, staff, children served at any one time from that indicated on this application. Additional approval is required for continued licensure if there are any changes in the conditions on which any earlier licensure is granted. The official license to operate a child day care center/home must be posted on the premises of the center/home in a conspicuous manner. The facts as stated in completion of this application are true Signature of Operator or Legal Representative fal ,-71b� Date T:\Grp&Ctr\Application\G_C_InitialApp.doc 0712/05 CT Department of Public Health (Attachment IIf) Division of Community Based Regulation Consultant/Head Teacher Data Sheet PLEASE PRINT-Please enter complete information for each Consultant and Head Teacher. Enter N/A(not applicable)for questions that do not apply CURRENT AGREEMENTS FOR ALL CONSULTANTS MUST BE SUBMITTED WITH THIS FORM Name of Person completing this form: Lee l (1 1 Position: (A-pc Date form completed: Program Name: 1 rj 1 I(1 Q� �S �' �JL&C(� License# Street Address: I0 - �i�Q(,� Town: � Q(CT Zip:_110 -7 4 Telephone#: ( = _ a Fax#: (__) -. Qj C Email fV Health Consultant(Required) Last name: 1 W--a—p u rVlp 1��_First:_ i Middle initial: Resident Street Address:_,3S 9 c50 d °L(_ k down:NDr4w16Q( : Zip: U(o DCpC) Telephone#: (j&P)) _3. Y;" II Fax#: I ) (SSE _ a I� E-mail: /v Work Address: S(,t Town: State: Zip: Telephone#: ( - Fax#: (_ - E-mail: Professional license held: ❑Physician[]Physician Assistant[]AP Registered Nurse registered Nurse Professional License#: _P\3 55,5� —7 License Expiration Date:_ Early Childhood Education Consultant(Required) Last name: Ba�® First: KoA)L� Middle initial: Resident Street Address: I SCQ(60(c LAI Town: r` WState:__Lf Zip:_ Ll Telephone#: Fax#: (_� _ E-mail: Work Address: Town: State: Zip: Telephone#: ( ) - Fax#: L_) - E-mail: DPH approval on file: ❑ Yes RN"'o Name at time of approval if different: PLEASE BE SURE TO COMPLETE THE REVERSE SIDE OF THIS FORM �" I �0`� � � u� Dental Consultant(Required) Last name: N C rO ) S First: _ pl- t/l dati Middle initial : Resident Street Address: Town: State: Zip: Telephone#: Fax#: (_ ) - E-mail: Work Address: 1E Lai t call &. Town: f W y�§ge; C Zip: 0(oo]� Telephone#: ( Rl,,()) ------ Fax#: � _ 4-'�q 7_E-mail: Professional license held: [Ly icensed Dentist ❑Dental hygienist Professional License#: _ 'j t I Expiration Date:-___t,) A Social Service Consultant(Required) Last name: �+It t First:_ ct r o Middle initial: Resident Street Address:3A Town:arml,4AState: _Zip: Telephone#: (8Lpb ) 5-b 1 - lC_Fax#: ( /hP) _ E-mail: Work Address: sQ as Gt oOy Town: State: Zip: Telephone#: ( - Fax#: (_� - E-mail: Professional degrees held: ❑BSW [OBA/BS -Field of study: 1(*/)1 C0_1 RUC(DIC)QU ❑MSW ❑MAIMS-Field of study: Professional License# (if applicable): t 6 p Expiration Date: Registered Dietitian Consultant(Required for programs that serve meals) h Last name : First: Middle initial: Resident Street Address: Town: State: Zip: Telephone#: (_ Fax#: (_� - E-mail: Work Address Town: State: Zip: Telephone#: ( ) - Fax#: ( - E-mail: Professional license held: ❑RD License/ID#: Expiration Date: CURRENT AGREEMENTS FOR ALL CONSULTANTS MUST BE SUBMITTED WITH THIS FORM Head Teacher(s)(Required) Please complete this section for each Department Approved Head Teacher at this program. If your program has more than(1)Head Teacher,please submit this information as an attachment, Last name: M e, �{ First: _�i(1 (' ( _Middle initial: Resident Street Address 19 9 B u Town: State: _CT Zip; to ,f} 11 ' Telephone#: — Fax#: �� ry�E-mail: Work Address: Town: SQLI -{�twj,`�fa �—Zi p: Telephone#: Q 5aB _ Fax#: (—� __S$,JnL_E-mail: PJ A Dept.of Public Health approval on file: s [:]No nder 3 Years [preschool chool Age Name at time of approval if different: N Please return this form to: Department of Public Health,Division of Community Based Regulation, 410 Capital Avenue MS#12 DAC,P.O.Box340308,Hartford,CT 06134-0308 or Fax(860)509-7541 T:/.Grp&Ctr/Application/G_C_Consultants.doc 12/3/2003 Attachment 15 Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Educational Program Plan All of the children enrolled at Rising Stars Childcare will follow a flexible daily schedule that meets the individual needs of the diverse population served by our program. The plan for development will allow for cultural, language and development differences to be addressed. There will be sufficient opportunity for indoor and outdoor physical activities,which will allow for fine and gross motor development. The schedule will include opportunity for problem-solving experiences that help to formulate language development and sensory discrimination. Children will have the opportunity to express their own ideas and feelings through creative experiences in all parts of the program including, but not limited to: • Art and media • Dramatic play • Music • Language • Motor activity • Language learning experiences • Experiences that promote self-reliance • Health education practices • Child initiated and teacher initiated experiences • Exploration and discovery • Varied choices in materials and equipment • Individual and small group activities • Active and quiet play • Rest,sleep or quiet activity • Nutritious snacks • Toileting and clean up STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH SUPPLEMENTARY INFORMATION OF INFANT/TODDLER DAY CARE PROGRAM IN DAY CARE CENTERS AND GROUP DAY CARE HOMES PUBLIC HEALTH CODE SECTION 19A-79-10 UNDER THREE ENDORSEMENT "The operator of a program caring for children under three (3) years of age shall comply with sections 19a-79-1a through 19a-79-8a and section 19a-79-10 of the Regulations of Connecticut State Agencies. Complete original application, answering all items as they apply to your Child Care Center/Group Day Care Home: Please send: orizinal application to your Day Care Licensing Specialist Please keep: one complete copy on file at licensed premise S1. Name of Center/Home: _ R j,S j n 0, +rA« i �� L LL IJ Location Address: �(Yl Gt umber&Street/Road) Town/City/State: scu 4-1 W i n dsoC T Zip Code: D —d L Telephone on Premises: �(QQ - �j LS - -7 5 '01 C) S2. LICENSED CAPACITY AND ENROLLMENT: Requested licensed capacity for children under three years of age: S3. GROUPING OF INFANTS/TODDLERS: Sketch indoor program space and specify the following: (Attachment#S3) a. Dimensions+total square footage(in FEET)of each room/program area. b. Relationship of this space to any other program space. C. How groups of eight are divided with physical barriers. d. Where sinks and changing tables are located. 2 till �� -52- S4. NURSE CONSULTATION: Attach a copy of the following: (Attachment#S4) S4 Name, resume and copy of current registered nurse's license. S5. HEALTH AND HYGIENE: Develop the following written policies and procedures and attach copies: S5a. Diapering and toileting, including a description of the diapering procedure, the disposal of soiled diapers,hand washing procedures and sanitizing procedures. (Attachment#S5a) Cloth diapers used: ❑ Yes Eg/No S5b. If cloth diapers are used, submit a plan describing the procedures used to handle soiled non- disposable diapers and clothing. (Attachment#S5b) N117AT The licensing authority (Department of Public Health) must be notified of any change in plan of operation involving facility, staff, children served at any one time from that indicated on this application. Additional approval is required for continued licensure if there are any changes in the conditions on which any earlier licensure is granted. The official license to operate a child day care center/home must be posted on the premises of the center/home in a conspicuous manner. The facts as stated in completion of this application are true A 0- Q - rA j )dkA/-) Signature of Operator or Legal Representative Date T:\Grp&Ctr\Application\G_C_InitialAppSup.doc 07/13/05 I+HCL c�h rn 6A+- S OBJECTIVE To provide consultation and training to promote the safety and well being of children, parents and staff in an interesting, energetic and understandable manner. EDUCATION BSN,Saint Anselm College May 1981 EMT, Hartford Community College November 1989 First Aid/CPR Instructor Certification October 1983 CPR Instructor Trainer American Heart Association May 1998 QUALIFICATIONS Independent, Positive Energy and love for diversity WORK HISTORY President/Owner February 1991-present of Nurse Consultants LLC Evaluate, Implement,and Manage ongoing training within the "Licensed" Day Care setting. Provide high quality training and inservices to clients, as well as on site consultation. Antepartum/Postpartum staff nurse-November 1991-June 2000 University of Connecticut Health Center Provide care for"High-risk" mothers. Nursing Supervisor-March 1988-November-1991 University of Connecticut Health Center Management position assisting staff in problem solving to promote optimal patient care. REFERENCES Jacqui Maxon---844-8066 (Director Apple Tree Granby) Kristen Yankouski--408-9467 (Director Little Lambs & ivy, Simsbury) Joni Schneider--549-2422 (Owner Joni's Child Care) 259 Silver Street North Granby, CT. 06060 Phone: 1-860-653-5269 Fax: 1-860-653-9214 Email: NConsulton@aol.com a.GQ rnen 5 FAttached nsed/Certified Professional, ou will find your validated license/certification ing year. Should you have any questions about Your license/certificate renewal, please do not hesitate to write or call; Department of Public Health P.O:Box 340308 (860� 509-760 0001371 •P ""PRSRT T4 0 0664 06060 M.S.#12MOA ROBIN L. YOUNG-COURNOYER RN Hartford, CT 06134-03M http'//Www.dph.state.ct.us 259 SILVER ST NORTH GRANBY CT 06060 Sincerely, J. R08ERT GALVIN, MD, MPH, COMMISSIONER DEPARTMENT Of PUBLIC HEALTH . j ROBIN L. YOUNG COURNOYER RN TLj'CT LICENSE NO.I - i_ J; 03 445414 R3555 7 02/29/08 THE INDIVIDUAL NAMED BELOW IS LICENSED (` \` REGISTERED NURSE BY THIS DEPARTMENT AS A REGISTERED NURSE LICENSE NO. CURRENT THROUGH i ST„TF o ROBIN L. YOUNG-COURNOYER RN 02/29/08 4 VALIDATION NO. 03-445414 v\.,f ROBIN L. YOUNG-COURNOYER RN Ii%; LICENSE NO. 03-445414 R3S557 02`/29/08'' REGISTERED NURSE --- _ conZvssiotvstz ' a s5 HOW TO CHANGE A DIAPER 1. GET ORGANIZED • Before you bring the child to the changing area,gather what you need: non-absorbent paper. Fresh diaper,wipes,gloves,change of clothes. • Staff must wash their hands and the child's hands prior to all diaper changing • Put on the disposable gloves 2. AVOID CONTACT WITH SOILED ITEMS AND KEEP A HAND ON THE BABY 4 • Anything that comes in contact with stool or urine is a source of germs • Carry the baby to the table,keeping soiled clothing away from you • Bag the soiled clothing and securely tie the bag to send home 3. CLEAN THE DIAPER AREA • Unfasten the diaper - - • Use disposable wipes or fresh,wet paper towels to clean diaper area. Remember: clean front to back with a clean wipe each time. Put the soiled wipes in the soiled diaper • Report any skin problems 4. REMOVE THE SOILED DIAPER AND CLEAN SURFACES • Fold the diaper over and secure with tabs • Put diaper in a covered,lined step can which is to emptied at least once daily • Check for spills • Remove the gloves and put into the step can • Wipe your hands 5. PUT ON THE CLEAN DIAPER 6. CLEAN THE BABY'S HANDS • Use soap and water at the sink if possible or use a disposable wipe , • Dry hands with a disposable paper towel 7. CLEAN AND DISINFECT THE DIAPERING AREA • Dispose of the table liner • Clean any visible soil from the table Disinfect the table with a disinfecting solution • Leave the disinfectant on the table for two minutes,the wipe dry or allow to air dry 8. WASH YOUR HANDS AND RECORD ON DAILY LOG J t • Use soap and water •. Use paper towel to turn off faucet • Record action on daily log **REMINDER: STAFF AND CHILDREN'S HANDS ARE TO BE WASHED BEFORE AND AFTER DIAPER CHANGING. COVERED GARBAGE CANS ARE TO BE EMPTIED AT LEAST ONCE DAILY. 12/20/2007 THU 11:36 FAX 860 644 7280 South Windsor Town Hall 2001 ********************* *** FAX TX REPORT *** ********************* TRANSMISSION OK JOB NO. 4795 DESTINATION ADDRESS 95097541 PSWD/SUBADDRESS DESTINATION ID ST. TIME 12/20 11:36 USAGE T 00' 14 PGS. 1 RESULT OK co V : ��Osox•coN`��` 1540 SULLIVAN AVENUE•SOUTH WINDSOR,CT 06074 TELEPHONE(860)644-2511 December 20, 2007 Julie Boscarino { Child Care Licensing Specialist E State Health Department 410 Capitol Avenue MS#12 DAC Hartford, CT 06134 f Dear Julie: s } The proposal of Creative Kids at 27. Ellington Road South Windsor to increase the under three capacity is approved by this office f Very truly yours, AVDeula,ORS./(' Environmental Health Officer RD/cm ! • F ' 3 • 1 Creative Kidz Child Care, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 December 19, 2007 Re: Rising Stars Childcare dba, Creative Kidz Childcare - License# 16012 Dear Bob, Enclosed please find the following revised items that the State requested from the Initial Licensing Application: • Fee Invoice Form with additional $150 toward 2-year Initial Licensing • Page 5 of application—Revised# of toilets & sinks • Revised Affidavit • Proof of Workers Comp Insurance • Attachment 5b • Attachment 5c revised • Lead Corrective Action Plan(awaiting approval from local health) • Lead Management Plan(awaiting approval from local health) • Attachment 8b revised • Attachment 8e revised • Attachment 1 Oa revised • Attachment 13b—including lead water test results and water bill • Attachment$5a revised with Hand-washing Policy I am still awaiting the following items: • Attachment 5a(awaiting approval, revisit on 12/21/07) • Attachment 1 Ob (pending paperwork) • Attachment 11 a(awaiting transcripts from consultant) I have included the Lead Corrective Action Plan and the Lead Management Plan. The Corrective Action Plan will be completed by December 31, 2007. I will call you to set up a time when you can inspect the corrections. I also request that the State change my Under Three Endorsement from 24 children to 36 children. Julie Boscarino has been out to measure the new room and gave me a Corrective Action Report to complete. However, she told me that I also needed your approval in writing to change my endorsement. I am currently working on the plan and the paperwork for the new"Two's" classroom. You will receive that information shortly. Please contact me if you have any questions or concerns. Sincerely, Renee C. Welch Director Oia-r Visual Inspection Sign-Off Sheet On Monday of every week, a visual inspection should be conducted of each surface of the room to check for chipping, peeling, scratched or missing paint. Please include the date, what was observed and your signature. If you have any questions, please see Renee. Date Observation Signature STATE OF CONNECTICUT . DEPARTMENT OF PUBLIC HEALTH Division of Community Based Regulation Child Day Care Licensing—Fee Invoice Form The licensing fee is due with your application to obtain or renew a child day care license. THE FEE IS NON- REFUNDABLE. Please complete items 1 through 10 of this form. If you have questions, call the licensing office at 1-800-282-6063, 1-800-439-0437 or(860) 509-8045. Make your payment by check or money order payable to: TREASURER-STATE OF CONNECTICUT. Mail this form along with your payment and application to the Department of Public.Health at the address on the bottom of this form. f 1. Name of Licensee or Applicant: P P{� �4 € c rk � /� i (Legal Operator) 2. Program Name: j. t�k t i 1 L L �-- (Applicable For Group/enter Only) 3. Program Location Address: CT Street Address Cuy/Town Zip Code 1. Program Phone Number: D. Program Fax?dumber: 5. License 4: Expiration Date: / (For Relicensure Only) (For Relicensure Only) 6, Mailing Address (if different): CT Street Address City%Town ,Zip Code 7. Program E-mail Address: tJ /"' CIO S. Enclosed Check/Money Order: $ (U. 0(- Check : J Check Date: 9. Social Security#: - - or Federal Employer ID 1*: aw - -" (3 digits) (2 digits) (4 digits) (2 digits) (7 digits) l 0. Pavment is for the following type of license: (check one box below) Child Day Care Center Group Day Care Home )Family Day Care Home u Account42431) (Account 1'_1311 (Accountrc4 43l) �Yy, li ua15C (new program) ❑ 6-month license(new program) I ❑ 2-year license (nev, pro�'ider) $30.00 S20.00 2-Fear license(reticensure) 2-year license (reticensure) 2-year license(relicensure) S20.00 $200.00 $100.00 Phone: (860) 509-8045, Far: (860) 509-'41 _ Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue-AIS 12CBR P.O. Box 340308, Hartford, C7' 06134 An Equal Opportunity Employer T:\Fam&Ctr\Aoolication\CDC FeeForm.doc 3/22/04 4W, I � RISING STARS CHILD CARE, LLC 27 SPIELMAN ROAD SOUTH WINDSOR, CT 06074 155 F i (860)528-7529 51-7031/2111 f DATE PAY TO THE ORDER OF ROCKVILLE BANI K DOLLARS LJ Snclud dfaatures CO N N EC II CIIT'S SE 51` Deiails on back. 2baci�ll y Bgnk:_ MEMO - VAk 110000 L 5 Su• 1: 2 L i l PO 3 18�: 0 5080009 2 ?Su rtmn s*ape:e:ve mnnrrioner. .;,;.'"•°..' Y , 5 .b. WATER SUPPLY. (check one)(Attachment#1 3b) b) Ci"unicipal ❑ Well 1 Other If If water source is City/Muniiciipal. submit c documentation for verification u pY of most recent bill or other (Attachment#13b) Purposes-with oprogram's location address on it. 2. Submit copy of Lead Water Test completed every ve(Attachment#13b) ry 2 years for All water. 3• If water source is a well, submit a co every two years (Attachment#13b) pY of the Bacterial and Chemical Test 4• If water source is a well and facility will serve 2S or children for over 60 days per year, the facilitymore adults and required water quality testing and well construction for non cost be in mmunity public for water systems per CT Public Health Code Sections 19-13-B 102 and I9-I3-B51 respective) tY public Y Information must be verified with DPH Drinking at(860)509-7333. bg Water Division • Water Supply Engineer Contact Person: +1C;? Print Name C. Number of toilets for children:•3 Number of toilets for staff/adults: Number of sinks for children: _� Number of sinks for staff/adults: d PETS-If pets are present in the,program submit to children. (Attachment#13d) N /A t a written Plan for their care and access e RADON TESTING: If the program is located in a basement level or submit copy of radon test. Results must be posted. Testing ground floor between the months of November and April. (Attachment#13e be done 14. OUTDOOR PLAY SPACE: (attach CO Pies e ies of the following) > a. Sketch showing dimensions in FEET. Include information on location of facility, equipment,type of surface(s), fencing and storage areas. (Attachment#14a) major play b Copy of official swimming pool approval to indicate compliance with Public Health Code, if applicable. 15. EDUCATION PROGRAM; Child Day Care Centers/Group Day Care Homes shall have policies, procedures and activities that meet and enhance the needs of children served. Attach the following information for age groups served: • Educational Pro ram Plan: Describe the educational program plan, which meets and enhances the individual needs of the diverse population of children serviced, including provide indoor/outdoor physical activities, problem solving experiences, cxeativeow eartsogra activities, language learning experiences, self-reliance/self esteem experiences and health education activities. P" l rya ►/o STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Child Day Care Center or Group Day Care Home AFFIDAVIT NOTE: This form must be completed by the Operator or the individual authorized to represent and act on behalf of the Operator. I' -- PeAq e C ` Wei cin being duly sworn depose and say: Name of Legal Representative(this is the individual authorized to act on behalf of the operator)or Operator(only if Operator is an individual) The name of the child day care center/group is ki.Si n (-S La L L C- e of Child Day Care Center/Group Day Cafe Home The application is made to conduct this child day care center/group day care home at: ? ��+ �JY1 CA ll C ( i E nC�SD�( GT 0 7�-f Location Address: Street City/Town State Zip Code The Operator of the above named facility is a: (please check one of the following and include the name) ❑ Individual/Sole Proprietor Vimited Liability Company iSt✓x' Sfacs i1d6t re, (name of Individual/Sole Proprietor) name of LLC) ❑ Corporation ❑ Partnership (name of Corporation) (name of Partnership) ❑ Limited Partnership ❑ Limited Liability Partnership (name of LP) (name of LLP) I am the Operator and am legally responsible for the operation of said program or I am the Legal Representative and am duly authorized and empowered to act as of this date on behalf of the Operator. My phone number is( Y&O , -7-7 Q(4 _ My address is $ Street,City/Town,State,Zip Code (have read the Connecticut General Statutes and Regulations of Connecticut State Agencies(Public Health Code)relating to the licensure ind operation of a child day care center/group day care home. Che information contained in this application is true and indicates compliance with the aforementioned Statutes and Regulations. will ensure that this program will be operated in compliance with the aforementioned Statutes and Regulations and with any Consent order executed with the Department of Public Health or any successor agency. give my permission for a full unannounced inspection of the facility and a comprehensive review of the program and staffing plans for he child day care center/group day care home by the State Department of Public Health, and the local health department for the purposes vithin their authority,at any time throughout the period for which the license is issued. understand that the Department of Public Health must be immediately notified of any change in the plan of operation affecting any ondition contained in the application upon which the license is renewed and of any change in the legal representative. understand that the license is time limited, is subject to review, and that renewal is necessary for continued operation of the child day are center/group day care home. my false statements made herein are punishabl 'n accordance with Section 53a-157b. Signature of Operator or Legal Representative Subscribed and sworn to befo=the � � day of Month Year i Sign ure of notary public,commissione of superior court or other proper official as noted in Connecticut General Statute Section 1-24 My Commission EV.W.31,2011 3rp&Ctr\Application\G C_Affidavit.doc 6/22/06 NORTH AMERICAN SPECIALTY INSURANCE COMPANY WORKERS COMPENSATION EMPLOYERS LIABILITY Domiciliary office: (800)542-9200 A Stock Insurance company INSURANCE POLICY 650 Elm Street; Manchester:NH 03101-2524 Administrative Office: Policy Number Policy Period P. O. Box 50457:Sarasota, FI 34232-0303 From To WCA 0027234 �121%-M- 0/2007 10/30/2008 i Standard Time at the described location i POLICY DECLARATION Transaction Named Insured and Address i RISING STAR CHILD CARE LLC Agent 27 SPIELMAN RD GE COMMERCIAL INS APPAACHIA i L N SOLTT U/W'S WORKER'S COMP P WiNDSOR CT 06074-4151 R04RAM 800 OAK RIDGE TPKE STE A-1000 I OAK RIDGE TN 37830-0000 Telephone: 888-376-9633 0900009 Carrier# FEIN# 2414 7 Risk ID#261194802 Entity of Insured LTD LIAB CO Additional Locations: 2. The Policy Period is from 10/30/2007 to 10/30/2008 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: CT B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States insurance: Part THREE of the policy applies to the states, if any, listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WEST VIRGINIA, WYOMING, STATES DESIGNATED IN ITEM 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $514 Total Estimated Annual Premium $2, 291 Assessments and Taxes Expense Constant $2oc Premium Discount Deposit Premium S2, 291 This is a Three Year Fixed Rate Policy Premium Adjustment Period: [Z Annual; ❑ Semiannual; ❑ Quarterly; E- 1 Monthly Countersigned this Day of , Issued Date: 11/01/2007 Authorized Representative Issuing Office Sarasota, FL 00 SPOO1407 Ed (02.01) wwc000001A (05•88) INSURED COPY Palle I of 4 WORTH AMERICAN SPECIALTY INSURANCE COMPANY WORKERS COMPENSATION EMPLOYERS LIABILITY INSURANCE POLICY Policy Number. wCA o027234 --' Named Insured' RISING STAR CHILD CARE LLC Agent: GE COMMERCIAL INS APPALACHIAN 0900009 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Code Premium Basis Rate Per No. Classification Description Total Est. Annual $100 of No. AnnuConnecticut Remuneration Remuneration Premium Unit 00001 CHILD DAY CARE CENTER-PROF EMPLOYEES & CLERICAL,SALESPERSONS 1 Unit Total so,000 _.28000 _N 2Ni) iNJL:RY ?;;ND PREMIUM $ 1, 920 SURCHARGE CM2,180 r �350G FAM CT w/C COMMISSION ASSESSMENT y ,920 ^'SOC Y- DOMESTIC TERRORISM, EARTHQUAKE AND INDUSTRIAL ACCIDENTS 35 40 FO^EiGN TERRORISM -50,000 G. 0,,. .5 150,000 O.C3000 �a0 EY.P_NSE CONSTANT State Total zec Policy Total $ 2, 291 $ 2,291 issued Date: 1.1/01 /2007 SPOC.405 Ed.(02-01) VVCS-98901 (02.01) INSURED COPY Paac '_ of'4 APPROVAL FOR CHILD DAY CARE ❑ Town Zoning Department *�. Town Building Department ❑ Town Fire Marshal ❑ Director of Health ANFNInspection ❑ Architectural Review ❑ Administrative Review HAS BEEN COMPLETED ON: Child Day Care Center /❑ Group Day Care Home LOCATED AT: 7 ��1�L. / 6 1-- 0 (StreetAddress) (Town) (State) AP) IS CONSTRUCTED IN ACCORDANCE WITH APROPRIATE USE GROUPS AND: Connecticut State Building Code (CGS sec. 29-252-1 c) ❑ Connecticut State Fire Safety Code (CGS sec. 29-292-8d) ❑ Chapter 30—New Day Care Occupancies I ❑ Chapter 31 —Existing Day Care Occupancies ❑ Other i (list code title,edition,and section) ❑ Town Zoning Regulations ❑ Health Ordinances PRELIMINARY APPROVAL IS GRANTED FIN PPROVAL IS GRANTED ?r45 ' &06'2 Signed: Title: oNTG-�tNo-- a �� Town: SQcM &�iNDS6��' _ G I�_f,-off Date: ��- 7 1lUf iN(s ( �t4iC` i s:OivisionlLicensurc\Grp&ctr\Field Forms\Generic Local Approval for Child Care.doc 9111106 Zoon/aoa APPROVAL, FOR CHILD DAY CARE 2 Town Zoning bepartment El Town Building Department ❑ Town Fire Marshal ❑ Director of Health AN ❑ Inspection [] Architectural Review Administrative Review HAS BEEN COMPLETED ON: N Child Day Care Center ❑ Group Day Care Home LOCATEDAT: i ��G cc�� C�✓J Cell dd CC(ee- e�-7 iej�gafA lj (Stivet Address) (Town) (State) (dip) IS CONSTRUCTED IN ACCORDANCE WITH APROPRIATE USE GROUPS AND: ❑ Connecticut State Building Code (CGS sec. 29-262-1 c) [] Connecticut State Fire Safety Code(CGS sec. 29-292-8d) ❑ Chapter 30 w-New Day Care Occupancies f ❑Chapter 31 -Existing Day Care Occupancies ❑ Other (list code title, edition,and section) Town Zoning Regulations ❑ Health Ordinances ❑ PRELIMINARY APPROVAL IS GRANTED FIN L APPROVAL IS GRANTED Signed: Title' Town: �JL3 Ire1 f1�� 'jt� Date: 1 ( s;lDivisionT!censurelGrp&ctAField FormAGenerio Local Approval ft Child Carti.doc 911 IM6 Attachment 8b Closing Time Plan Rising Stars Childcare closes at exactly 6:OOpm Monday through Friday. At closing there are always 2 staff members present regardless of the amount of children in attendance. Should a child not get picked up on time the following policy is put into effect: While one staff member supervises the child, the other staff member will call each parent. If they are unable to contact the primary caregivers, the staff member will then try to reach each emergency contact person that the parent listed on the Registration Paperwork, for alternate pick up arrangements. The owners will also be contacted. Once all parties are contacted, if there is no answer, we will wait up to 45 minutes before contacting the South Windsor Police Department. 1"I (9 J0 Attachment 8e Rising Stars Childcare, LLC 27 Spielman Road South Windsor, CT 06074 860-528-7529 Operating Policy Days and Hours of Operation Rising Stars Childcare is open Monday through Friday from 7:00a.m to 6:00p.m.,year round. We are closed for the following major holidays; New Year's Day, Memorial Day, Independence Day, Labor Day,Thanksgiving Day,the day after and Christmas Day. If there are going to be any changes in holiday closings, Rising Stars Childcare, LLC will give parents and Staff at least 60 days notice. Admission A$50 registration fee is due upon registration. Tuition payments are to be made weekly and are due the Friday before the week of care. At the time of enrollment we require the following: • An updated physical form,signed and dated by their pediatrician. Infants must bring in copies of all of their recent immunizations. All children's physicals must be updated annually,including updated immunizations as they occur. All children must update their physicals annually until they turn school age. Once they are of school age we require updates only as their school requires updates. • Our registration packet completed and signed including accurate emergency contact numbers. Any changes in address, phone number,employment,etc.,must be given to the Director in writing. Agreement with Parents 1. Please call and let a teacher know if your child is going to be absent for any reason. 2. An adult must accompany your child to and from their classroom every day. 3. Your child will have their own cubby space for belongings. Please leave at least 2 spare outfits(weather and size appropriate)in your child's cubby. 4. Parents must supply diapers,wipes, a bottle for all feedings,bay food,formula, etc. (If your child is 1 year or younger,the parent should supply all dietary needs. As the child is able to eat solids and enjoy whole milk,the center does supply 2 snacks per day plus milk and juice.) 5. All items brought in should be labeled including food and bottles. 6. Toys are not to be brought in from home. There is no need to bring in personal items because we provide all toys and daily activities. 7. Parents are to supply sheets and blankets for porta-cribs or cots. Please have a "snug-fitting"spare, labeled sheet in your child's cubby. 8. In case of inclement weather, please watch WFSB-TV Channel 3 Early Morning Network Storm Closing System for closings or delays. Meals or Snacks Parents supply all meals. The center will provide morning and afternoon snack as well as Milk and 100%fruit juice throughout the day. Weekly snack schedules are posted in a conspicuous place. e tt'o is 11a) J Parent Involvement Rising Stars Childcare has an open door policy. Parents are encouraged to visit their children whenever possible. Access to Program and Facility The center plans for periodic educational and fun field trips. Parents will always receive a permission slip for each field trip. The child can not attend the trip without the signed permission. Parent volunteers are more than welcome. Provisional Enrollment Period There is no provisional enrollment period. Withdrawal of Children Parents must give at least two weeks notice when withdrawing their child from the center. All tuition due through the two weeks remains due. Medication Policies The Center will only administer non-prescription topical medications,diapering and teething ointments. All ointments and topical medications must be brought in their original containers. Proper forms will be given out upon enrolling and must be filled out by the parents. Date:__ JO j (Attachment#10a) Program Name: k Location Address: Phone Town: License Mailing Address: Prepared BY: —��Cc Town:------- State: Zip Code Date: STAFF WORK SCHEDULE FORM DATE OF WORK SCHEDULE STAFF NAME v MIRTH POSITION DAYS AND HOURS DATE HIRED tA - F em Neon ' I .0 12-7 7 n tl 0 4)2 7o , f�2 )a r 55a L.Lzad� I lls� -�o PM 25ha�) (n Lo r e (w- f A -MLE-1--UPM Kwic Place (an asterisk) by each person's name who has been First Aid Trained within the last 3 years Place v (a heart)by each person's name who has valid CPR Training T:\Grp&Ctr\Application\G-C-Initialstaffwork-Sch..doc 4/30/03 RETURN TO: I� �InJ� �