Except for nature-based programs that operate solely outside, programs shall conduct fire drills in accordance with the following: Programs that operate continuously throughout the year shall conduct at least one drill each month of operation.

The licensing coordinator's review of program fire drills revealed that no drills were conducted in the months of February, May, June, and July of 2025. Corrective action: To ensure compliance with fire drill requirements, a recurring reminder has been set for the third Thursday of each month, and written reminders have been posted in the teacher workspace to support staff in consistently completing required drills. Ongoing compliance will be maintained through year-long calendar reminders and continued in-classroom postings to ensure each drill is completed and documented appropriately. This citation can be corrected immediately, as a fire drill is already scheduled for November 21 and monthly reminders are in place to ensure consistent and timely completion moving forward.

He-C 4002.16(a)(1) · Correction status not published

Any contaminated, expired, or discontinued medication, whether prescription or over-the-counter, and topical substances shall be returned to the child’s parents or guardians whenever possible or, if belonging to the program, disposed of properly by authorized staff.

The licensing coordinator's review of program medications revealed that one EpiPen, expired "7/2025," had not been returned to the child's parents or disposed of properly. Corrective action: The expired medication has been removed from the program, and the parent confirmed on November 7 that it is no longer needed. A medication-tracking spreadsheet has been created and fully updated with all current children and their medication expiration dates, and it, along with all medications, will be reviewed monthly with the support of a calendar reminder set for the first Monday of each month. This system ensures upcoming expirations are identified well in advance and that all medications in the program remain within valid dates. We have obtained written notification from the family stating that the allergy is no longer present and the medication has been removed from the program.