Cited finding
The Allergy/Medical Condition List was not posted. This was previously cited on 11/20/25 Visit #162470. This was previously cited on 3/10/26 Visit #174002.
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Home › MA › Roxbury › Twelfth Baptist Church After School Program
License #P-177801 · Center · Center-Based Care
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The Allergy/Medical Condition List was not posted. This was previously cited on 11/20/25 Visit #162470. This was previously cited on 3/10/26 Visit #174002.
Children's Records
Allergies, medical info, special diets, emergency medications; privacy protected
Staff Records
Building Inspection and Fire Inspection
Sound administration
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Data synced from Massachusetts Department of Early Education and Care on Jul 10, 2026 · Source records · Report an error
One staff file did not include an annual evaluation. This was previously cited on 3/20/25 Visit # 159694. This was previously cited on 11/20/25 Visit #162470 This was previously cited on 1/6/26 Visit # 173833. This was previously cited on 3/10/26 Visit #174002.
1) A current Children's Records Checklist was not available. 2) One child's file did not include the Arrival Mode of Transportation. This was previously cited on 3/10/26 Visit #174002
The program did not have a current Building Inspection. This was previously cited on 11/20/25 Visit #162470 This was previously cited on 1/6/26 Visit # 173833. This was previously cited on 3/10/26 Visit #174002.
The licensee has not ensured that the program is soundly administered by qualified persons designated with specific administrative and program responsibilities. Several items have been cited repeatedly without showing compliance. Sound Administration was previously cited on 5/1/24, Visit #145531
The Allergy/Medical Condition List was not posted at the time of the visit.
The program does not have a current Building Inspection. Please email EEC when the Building Inspection has been uploaded to the document library.
Staff Records
Health Care Agreement
At the visit, a support staff member left the main classroom with a child to go to the other classroom unsupervised. The support staff was not in compliance with the Background Record Check Policies.
One staff member who has been at the program for 6+ months did not have a current First Aid Certificate in their staff file.
BRCs on all potential employees
At the time of the visit, with children present, a child's medication was stored and observed accessible to the children. This was previously cited at the 11/10/25 visit.
The Fire Drill Log did not include a monthly drill as required for November 2025. This was previously cited at the 11/10/25 visit.
Emergency Evacuation
Building Inspection and Fire Inspection
Individual Health Care Plan (IHCP)
Staff Records
A child's Individual Health Care Plan noted that the child's emergency medication was to be taken every 6 hours as needed for coughing or wheezing. The child's Medication Consent Forms and the prescription label on the medication indicated that the medication was to be taken twice per day. The frequency of medication administration must be consistent. This was previously cited at the 11/10/25 visit.
Medication Storage
A child's Medication Consent Form for their emergency medication was not signed or dated by the parent.
EEC asked the PA to see the ice packs in the first aid kit, whereas this was cited at the previous visit. The PA reported that they did not have any ice packs.
Individual Health Care Plan (IHCP)
EEC Essentials Training completion
A staff member hired after 6/30/25 did not have evidence of completing the Essentials 2.0 training prior to working with children as required.
Allergies, medical info, special diets, emergency medications; privacy protected
Staff files were reviewed. 1) One staff file did not include 20 hours of PD training for the past year and a current annual evaluation. 2) One staff file did not include a current bi-monthly observation and current annual evaluation.
Food Storage, Sanitation & Safety
First Aid Kit (SLGSA)
Staff Records - R Apr 2025
Accurate attendance; arrival/departure times
At the visit, the attendance included that 4 children were present when there were 3 children present. A child had not been checked out of the program upon pick-up. The program must have a method of knowing exactly who is present at any time during the day.
The first aid kit did not include ice packs.
Children's Records
Individual Health Care Plan
Two children's Enrollment Form where it asks for any allergies or medical conditions were left blank. This non-compliance was previously cited on 10/16/24 Visit #154721.
One child's Individual Health Care Plan was not signed and dated by the child's parent.
The Fire Drill Log did not include a monthly drill for September 2024. This non-compliance was previously cited at 7/1/24 Visit #151343.
The program did not have a current Health Care Agreement. The Health Care Consultant must review the Health Care Policy and complete the agreement at the time of each license renewal.
A sampling of children's files were reviewed. One child's Enrollment Form where it asks for any allergies or medical conditions was left blank.
The program did not ensure that the program was soundly administered by qualified persons designated with specific administrative and program responsibilities. The PA/SC reported that they were not present on 9/9/24 and 9/10/24. 1) The only staff member present on 9/9/24 and 9/10/24 was group leader qualified. Anytime children are present a Site Coordinator qualified person must be present. 2) On the days that the SC/PA was not present 9/9/24 and 9/10/24, a child with a possible life-threatening condition was present. The group leader had not been trained on how to administer the child's medication should they require it. This non-compliance was previously cited at 7/1/24 Visit #1472223.
Emergency Evacuation - R Apr 2025
Emergency numbers
The Emergency Phone Numbers were posted. However, they did not include the name, address and phone number of the program's Health Care Consultant.
One child's Emergency Medication has expired. The prescription label for this medication has also expired.
Building Inspection and Fire Inspection - R Apr 2025
The PA showed EEC a quarterly fire inspection dated 6/12/24. The inspection did not include compliance with carbon monoxide detectors (information was blank). Please contact the inspector and ask that they complete that section and initial and date. Please upload the updated inspection to the document library and email EEC when completed. Non-compliance was previously cited at 5/1/24 Visit #145531 and at 5/29/24 Visit #151140.
The program's Integrated Pest Management (IPM) Plan has expired on the IPM Plan website. Please email EEC when a current indoor and outdoor plan with required signatures has been uploaded to the document library
1) The program's Children's Records Checklist was not available at the time of the visit. Non-compliance was previously cited on 5/1/24 Visit #145531. 2) Three children's files were reviewed. One child's Arrival Mode of Transportation was blank.
Current consent for administered medications - R Apr 2025
Medication Administration
Sound Administration
The program did have a current quarterly Fire inspection. However, section F2 regarding carbon Monoxide detectors was blank. Non-compliance was previously cited on 5/1/24 Visit #145531.
1) One child's Individual Health Care Plan (IHC) was signed 8/28/22 and has expired. This child had a second emergency medication. This medication did not have an IHC Plan.
Children's Records - R Apr 2025
Staff files were unavailable at the time of the visit. EEC could not verify if at least one staff member had current First Aid Certification.
Staff files were unavailable at the time of the visit. EEC could not verify if at least one staff member had current CPR Certification.
Emergency numbers were not posted and easily visible to parents, educators and visitors.
At the visit, a staff member left the program and went to the bus stop to get a child from the bus and bring them back to the program location. The staff member did not have an Transportation Attendance Log. The program must have a method of knowing who is present during all hours of operation including while transporting children.
Areas observed were not safe, clean, and in good repair. 1) In the Mills Classroom boys bathrooms, there was rust on the radiator cover 2) In the main classroom boy's bathroom, there was rust on the radiator cover. In addition, there was a small door on the radiator cover that was unable to shut properly. 3) In the main classroom, there was a large heavy box that included a picture of a basketball hoop leaning up against some shelving accessible to the children.
The current staff schedule was not posted in a manner where visitors, staff and parents can easily view.
1) The Fire Drill Log did include a drill conducted in 4/23. However, documentation did not include the number of children and the effectiveness of the drill (time it took to evacuation and any comments), 2) The program could not locate any written documentation for a drill conducted in 5/23.
Staff Records - R Apr 2025
Staff Schedule/Qualifications - R Sep 2025
Emergency Evacuation - R Apr 2025
1) One staff file reviewed did not include evidence of interview and date, evidence of 2 MMR's or proof of immunity, evidence of a current physical exam and evidence of an annual evaluation. 2) One staff file reviewed did not include evidence of a current physical exam and 2 doses of MMR or proof of immunity, current First Aid certification and evidence of completion of 12 Essentials.
Food not served beyond recommended dates
Staff Records - R Apr 2025
On the day the visit. the Program Administrator left the program with 3 children to go to pick up other children from the bus stop. The program attendance was not brought with the group. The program must have a method of knowing which children are present at all times.
1) Three children's files did not include a progress report mid-year for this school year. The Program Administrator informed EEC that progress reports were not conducted in 2021-2022 school year either. School age children must have progress reports prepared at least annually at the midpoint of the year. 3) Two children's files reviewed did not include arrival and departure mode of transportation. 4) One child's file reviewed did not include arrival mode of transportation. 5) The three children's files reviewed did not have written permission from parents to walk to the Boys and Girls Club bus stop with staff to pick up children from their school bus.
The last monthly evacuation documented was 8/22. Evacuation drills must be conducted monthly.
Staff meeting documentation
Evacuation drill log, all groups
Staff Records - R Apr 2025
1) One staff file did not include a current physical exam, evidence of 2 doses of MMR or proof of immunity, a current annual evaluation evidence of completion of the 12 Essential trainings and current First Aid Certification. 2) One staff file did not include a current annual evaluation and evidence of completion of the 12 Essentials trainings.
There was no documentation of monthly staff meetings for at least 2 hours with all staff.
There was no written documentation of evacuation drills being conducted in April 2022.
Building Inspection;Fire Inspection;Environment free of pests;Date of IPM-RApr25
There was no written documentation of evacuation drills being conducted from 9/21-present.
The IPM Plan is over one year old.
Review of one child's file included that the transportation plan was blank.
The program did not have a 2022 Health Permit.
1) One staff file did not include a current [REDACTED] exam, evidence of 2 doses of [REDACTED] or proof of [REDACTED], a current annual evaluation evidence of completion of the 12 Essential trainings and current First Aid Certification. 2) One staff file did not include a current annual evaluation and evidence of completion of the 12 Essentials trainings.
Staff Records - R Apr 2025
Review of the past years evacuation drill log included the following: 1) The program did not complete an evacuation drill in 11/19. 2) Documentation of the 2/24/20 drill did not include the route used.
Emergency #'s easily visible-all
Posted emergency numbers did not include the address of the Health Care Consultant.
Emergency Evacuation Logs
At the visit, three children's files were reviewed. 1) Two children's emergency medication was not accompanied by a Medication Consent Form 2) Two children's Individual Health Care Plans (IHC) did not include consequences if the medication is not administered, side effects of the medication, staff who were trained to administer the medication and who trained the staff on medication administration. 3) One child's file did not include documentation of a progress report for the 2019-2020 school year. 4) One child's emergency medication prescription label indicated that the medication is to be taken twice a day. The parent provided the program with the wrong emergency medication. Medication that is to administered twice a day should be given at the child's home. The parent must provide the administrator with the rescue medication that is administrated as needed.
Allergies, medical info, special diets, emergency medications; privacy protected
Staff files were reviewed. 1) One staff file did not include an annual evaluation and current First Aid Certification. 2) One staff file did not include their PQ Registry.
Staff First Aid Training
Staff BRC
Children's Records
Building Inspection and Fire Inspection
Financial Documentation
1) The program did not have a current Children's Records Checklist 2) Two children did not have evidence that their current physical and immunizations are on file at their school with a parent signature and date, or a current physical and immunizations on file. 3) One child's Arrival Transportation Plan was blank, and the plan was not signed/dated by the parent.
The program did not have a current Health Care Agreement reviewed and signed at the time of the license renewal. Please email EEC when a current Health Care Agreement has been uploaded to the document library.
The program did not have a current budget, including income and expenses. Please email EEC when a current budget has been uploaded to the document library.
Medication Storage
Children's Records
1) The program requires a copy of the children's current physical and immunization records. One child's physical was over a year old and had expired. This was previously cited at the 11/10/25 visit. 2) One child's enrollment form arrival and departure mode of transportation was blank.
1) The program did not have a current Staff Records Checklist. Please email EEC when this has been uploaded to the document library. 2) One staff file did not include evidence of an annual evaluation. 3) One staff file included that the staff member was group leader qualified; however, the file did not include documentation of education or verification of experience to qualify as a group leader. The staff file did not include evidence of PQ registry. This was previously cited at the 11/10/25 visit.
The program does not have a current Building Inspection. Please email EEC when the current Inspection has been uploaded to the document library. This was previously cited at the 11/10/25 visit.
At the time of the visit, with children present, a child's medication was stored in a filing cabinet drawer accessible to the children.
At the time of the visit, the door to the kitchen was propped open. There must be a barrier between children's activity space and the kitchen.
Kitchen barrier
The refrigerator did not have a thermometer. Therefore, EEC was unable to determine if food requiring refrigeration was being stored between 32°F and 40°F.
1) The program did not have a current Staff Records Checklist. Please email EEC when this has been uploaded to the document library. 2) One staff file did not include evidence of an annual evaluation. 3) One staff file included that the staff member was group leader qualified; however, the file did not include documentation of education or verification of experience to qualify as a group leader. The staff file did not include evidence of PQ registry, and completion of Strong Start 2.0 trainings.
Children's Records
Staff Records
Staff Schedule/Qualifications - R Sep 2025
First aid kit
Refrigerator temperature
Building Inspection and Fire Inspection
IPM Plans
Emergency Evacuation
Current consent for administered medications
The program requires a copy of the children's current physical and immunization records. One child's physical was over a year old and had expired.
The staff schedule that was posted was not accurate.
The program's Building Inspection has expired. Please email EEC when the current inspection has been uploaded to the document library.
The posted Allergy/Medical Condition List did not include accurate information regarding a child's medication.
The program's Integrated Indoor and Outdoor Pest Management Plan (IPM) on the IPM Plan website was over one year old and expired. Please email EEC when the plans have been completed, the required signatures have been obtained, and all information has been uploaded to the document library.
The Fire Drill Log did not include a monthly drill as required for April 2025 and June 2025.
1) A child's Individual Health Care Plan noted that the child's emergency medication was to be taken every 6 hours as needed for coughing or wheezing. The child's Medication Consent Forms and the prescription label on the medication indicated that the medication was to be taken twice per day. The frequency of medication administration must be consistent. 2) The above child's IHC Plan was not signed or dated by the parent.
There were yogurt packets in the refrigerator that had expired.
Emergency numbers
Transportation Attendance
Staff Records
Sound Administration
BRC Compliance
Health Care Consultant Agreement
Children's Records
1) One staff file was missing the date and evidence of an interview. 2) One staff file was missing a current Staff Information form, evidence of program orientation, and bi-monthly staff observations. Incomplete staff files were cited on 5/29/24 Visit #1531140 and 7/1/24 Visit # 151343.
The Emergency Phone Numbers were posted. However, they did not include the name, address and phone number of the program's Health Care Consultant. This non-compliance was previously cited at 7/1/24 Visit #151343.
On the day of the visit, a volunteer was present with the children. The program did not ensure that the volunteer was in compliance with EEC Background Record Check regulations regarding volunteers. This non-compliance was previously cited at 5/1/25 Visit #145531.
The program has staff pick up children from the public school bus at a bus stop. The program has been recording on attendance the time when the children depart from the bus. The program has not been recording on attendance, the time that the child safely enters the building.
Sound Administration
Integrated Pest Management Plan (IPM)
First Aid and Emergency Consent Forms
Staff Records
Emergency Evacuation - R Apr 2025
Individual Health Care Plan (IHCP) - R Apr 2025
Medication
Current consent for administered medications - R Apr 2025
The Licensee did not ensure that the program was soundly administered. EEC asked the group leader at the time of the visit, if they were aware of any children's allergies and/or medical conditions and accompanying medications, and the Group Leader replied no. This non-compliance was cited at 5/1/24 Visit #145531 and at 5/29/24 Visit #151140,
The travel emergency bag did not include the First Aid and Emergency Consent forms for any child who had joined the summer program starting 7/1/24. First Aid and Emergency Consent Forms to be taken when off-site or upon evacuation from the program. This non-compliance was previously cited at 5/1/24 Visit #145531 and at 5/29/24 Visit #151140.
1) One staff file was missing the date and evidence of an interview. 2) One staff file was missing a current Staff Information form. These non-compliances were cited at 5/29/24 Visit #1531140.
The PA informed EEC that they did not conduct a practice evacuation drill in June 2024. Evacuation drills must be conducted at least monthly.
One child's Individual Health Care Plan did not include which staff were trained, who trained the staff and parent signature/date.
One child had an emergency medication. The program did not have a current Medication Consent Form completed and signed/dated by the child's parent. This non-compliance was previously cited at 5/29/24 Visit #151140.
Children's Records Check List
The staff schedule that was posted was not current. Non-compliance was previously cited on 5/1/24 Visit #145531.
Medication
School bus drop off transportation documentation
The Program Administrator (PA) was asked to demonstrate how to administer a child's emergency medication. The PA was unable to demonstrate administration accurately. The licensee must ensure that at least one educator with training in medication administration is present at any and all times when children are in care.
The Fire Drill Log was reviewed. 1) The route used (to ensure alternate exits are practiced) was not included for each drill. 2) The Effectiveness of each drill (including the time it took for all children/staff to evacuate) was not included for each drill. 3) The November '23 and February '24 fire drill documentation did not include the time of day.
Emergency numbers
Individual Health Care Plan (IHCP) - R Apr 2025
Emergency Evacuation - R Apr 2025
Attendance Recording and Group Sizes/Ratios
Staff Records
Building Inspection and Fire Inspection - R Apr 2025
Allergy/Medical Condition List
Indoor Space
Staff Schedule/Qualifications - R Sep 2025
1) The program attendance for the day of the visit was not accurate. Upon review, it was noted that the children had not been signed in on attendance at the time of arrival. 2) On the day of the visit, the Program Administrator (PA) picked up a child from the bus stop. The PA reported that they did not have the Transportation Attendance with them when picking the child up off of the bus. Non-compliance was previously cited on 5/1/24 Visit #145531.
The licensee did not ensure that the program is soundly administered by qualified persons designated with specific administrative and program responsibilities. 1) Many of the items cited on the previous visit on 5/1/24 Visit #145531 have not been corrected. 2) There are children enrolled in the program with allergies/medical conditions and medications. A staff member was asked if there are any children in the program with any allergies or medications and they replied no. 3) On the day of the visit, there was a child present who was not enrolled in the program. 4) The Program Administrator did not respond to the 5/1/24 Visit # 145531 Plan for Compliance within 14 days of the visit.
1) There was a tall, thin and heavy box as well as a tall heavy carrier which included a canopy that was stored up against a wall accessible to children. 2) In the main boys classroom boy's bathroom, there was rust on the radiator cover. In addition, there was a small door on the radiator cover that was unable to shut properly. Non-compliances were previously cited on 5/1/24 Visit #145531.
The Allergy/Medical Condition List posted was not current. Non-compliance was previously cited on 5/1/24 Visit #145531.
Emergency numbers were not posted and easily visible to parents, educators and visitors. Non-compliance was previously cited on 5/1/24 Visit #145531.
The posted Allergy/Medical Condition List did not include that one child in the program has 2 medical conditions requiring 2 emergency medications. The posted Allergy/Medical Condition List did not include that a child in the program has a food allergy.
Two staff files were reviewed. 1) One staff file did not include documentation of interview; evidence of completion of 12 Essentials Training and professional development hours for the past year. 2) One staff file did not include a staff information form, evidence of a staff orientation and a current bi-monthly observation.
The Program Administrator was asked if they brought the child's First Aid Emergency Consent Form with them when they picked up the child from the school bus stop on the day of the visit. The Program Administrator replied no. The program must have authorization for emergency care for each child anytime they are off-site. Non-compliance was previously cited on 5/1/24 Visit #145531.
One child's medication was not in it's original box.
A child had 2 emergency medications. One Medication Consent form was signed/sated 8/28/24 and was now over one year old. This child's second emergency medication did not have a Medication Consent Form.
Medication
Sound Administration
The staff schedule that was posted at the visit was not current.
The Program Administrator/Site Coordinator was not on-site at the time of the visit. The program did not have a qualified person designated in charge on-site in their absence. The staff member present was an assistant group leader qualified.
Emergency medications readily available
1) A current staff records checklist was not available to review at the visit. 2) Staff files were not available to review at the visit.
At the time of the visit, the children's files were unable to be located.
There was a staff member present with the children. This staff member did not have a current Background Record Check (BRC).
Indoor Space
First Aid and Emergency Consent Forms
Individual Health Care Plan (IHCP) - R Apr 2025
EEC was informed that there were no children with IHC Plans currently enrolled in the program. However, EEC was unable to verify this because the Allergy/Medical Condition List that was posted was dated 2020-2021.
EEC was informed that there were no children currently enrolled with medication that may need to be administered during program hours. However, EEC was unable to verify this because the Allergy/Medical Condition List that was posted was dated 2020-2021.
Emergency Evacuation - R Apr 2025
Staff CPR Training - R Apr 2025
Administration
Staff Records - R Apr 2025
Staff First Aid Training - R Apr 2025
Staff BRC - R Sep 2025
Staff Schedule/Qualifications - R Sep 2025
Attendance Recording and Group Sizes/Ratios
First Aid Kit when off-site
Refrigerator temp. between 32-40 degrees; working thermometer in refrigerator
Building Inspection and Fire Inspection - R Apr 2025
Emergency #'s easily visible-all
At the visit, a staff member left the program and went to the bus stop to get a child from the bus and bring them back to the program location. The staff member was off-site with a child and did not have a complete First Aid Kit.
The refrigerator that stores the children's food did not have a thermometer. Therefore, the temperature of the refrigerator was unable to be determined. Food requiring refrigeration needs to be stored between 32F-40F.
The program did have a current quarterly Fire Inspection. However, section F 2 regarding carbon monoxide detectors was blank.
The licensee did not ensure that the program is soundly administered by qualified persons designated with specific administrative and program responsibilities. Several documents were unable to be located which included staff and children's files. The Allergy/Medical Condition List posted was not current. The lack of access to these documents compromised children's health and safety.
At the visit, a staff member left the program and went to the bus stop to get a child from the bus and bring them back to the program location. The staff member was off-site with a child and did not have a copy of the child's current First Aid and Emergency Consent Form.
The Evacuation Drill Log was unavailable for review at the time of the visit.
EEC was informed that there were no children with IHC Plans currently enrolled in the program. However, EEC was unable to verify this because the Allergy/Medical Condition List posted was dated 2020-2021.
The refrigerator in the kitchen area did not include a thermometer. Therefore, EEC was unable to determine if food requiring refrigeration was being stored between 32F-40F.
1) Two staff files reviewed did not include evidence of interview and date, evidence of 2 MMR's or proof of immunity, evidence of completion on 12 Essentials training certificates. 2) One staff file reviewed did not include evidence of a current physical exam and annual evaluation. 3) One staff file reviewed did not include evidence of bi-monthly observations.
Children's Records - R Apr 2025
Staff Schedule/Qualifications - R Sep 2025
Attendance Recording and Group Sizes/Ratios
refrigerator temperature
menu's
Outdoor Space - R Apr 2025
staffing qualifications
transportation attendance
Emergency Evacuation - R Apr 2025
A current staff schedule was not posted in an area easily visible to educators, parents and visitors.
Several items in the dry/non- refrigerated food bin were unopened; however, there expiration dates had expired.
The program did not have previous menu's available for review. Menu's must be kept on file for one year. Menu's should be posted.
The outdoor play area under the trees had some black weed plastic covering above the surface in some areas and then posted a potential tripping hazard to children.
On the day of the visit, the Program Administrator (PA) was the only staff member present. The PA left the program to pick up children at a bus stop. While gone, a child was dropped off at the program and the driver could not wait until the PA returned. The child was left with a church office staff member who is BRC'd. However, this church office staff member is not qualified as a group leader and muse be supervised by a group leader when with children. The program must submit a plan to EEC that includes how they will remain compliant when one out of the 2 staff member's is not present.
The program walks to the Boys and Girls Club bus stop to pick up children from the public school bus and walk them back to the program. The program did not have transportation attendance including the time that the children departed the bus and the time that the children arrived safely back to the program.
Staff meeting documentation
Children's records and checklist - R Apr 2025
Evacuation drill log, all groups
Required Inspections (as applicable)
There was no documentation of monthly staff meetings for at least 2 hours with all staff.
Children's Records - R Apr 2025
kitchen barrier
IPM Plan
Allergies, medical info, special diets, emergency medications; privacy protected
Staff Schedule
Program transportation plan
The kitchen door was observed open and accessible to the children. There must be a barrier between childrens activity space and the kitchen.
The program's on line Integrated Pest Management Plan is over a year old and must be updated yearly. Please update both the indoor and outdoor plans, print out and sign/date and upload to the portal document library.
The Allergy/Medical Condition List was posted; however, it was not posted in a manner that protects the privacy of each child.
Please upload a current staff schedule to the portal document library.
The program has not uploaded their Transportation Plan to the portal document library for review and approval.