The following deficiencies were observed at the time of the complaint investigation conducted on 5/29/26 for case #00169163 and are subject to changes pending programmatic review. A full inspection was not conducted at this time. A copy of the Notice of Inspection Rights was provided at the time of the inspection. Please submit the Plan of Corrections via the LMS portal within 10 days of receipt of the Statement of Deficiencies. During the exit interview, the following item was discussed but is not limited to: Availability of administrative staff in addition to required staff-to-child ratios. Ratios observed were: 1/2-year-old children: 1:6 3-5-year-old children: 1:9 There were 3 staff interviewed during this investigation. There were 4 staff files reviewed during this investigation. Documentation reviewed: Rosters, incident reports, Emergency Information and Immunization Record form. The Compliance Officers attempted to contact the complainant on 5/8/26 by telephone and 5/29/26 by telephone and email. The complainant responded on 5/29/26. Upon completion of the complaint investigation # 00169163, it was determined from observation, interview and documentation, that 1 of 1 allegation lacked sufficient evidence to be substantiated.

Disposition: Complete

The purpose of the inspection was to conduct complaint #00152939 investigation on 12/19/2025. A full inspection was not conducted at this time. A copy of the Notice of Inspection Rights was provided at the time of the inspection. Ratios observed were: 1-2 year old's - 1:4 3-5 year old's- 1:6 There were 2 staff members interviewed during this investigation. There were 4 staff files reviewed during this investigation. The Compliance Officer contacted the complainant via telephone on 12/24/2025. Documentation observed was: -Staff time sheets -Employee counseling forms -Email communication thread -Photos Upon completion of the complaint investigation, it was determined from observation, interview, and documentation that 1 of 3 allegations was substantiated. The other 2 allegations were unable to be substantiated due to a lack of sufficient evidence. The following deficiencies were observed and are subject to changes pending programmatic review. Please submit the Plan of Corrections via the LMS portal within 10 days of receipt of the Statement of Deficiencies. The following was discussed, but not limited to: 1. Ensure immediate access is given to the Department upon arrival.

Disposition: Complete