6.2.6.1 · Staff shall be able to hear all children of pre-kindergarten age and younger at all times, shall be able to see the children with a quick glance, and shall be able to physically respond immediately.

The program self-reported an incident involving supervision that occurred on 03/06/2026. A preschool aged child in the Gekko classroom was left unsupervised for approximately eleven minutes. The three (3) program staff and the other sixteen children left the classroom to go outside while this child was in the bathroom. The child exited the bathroom into the empty classroom, walked around the space, and entered the hallway two (2) times. In the tenth minute of the child being alone, he was approached by two (2) persons while in the hallway outside of the classroom. These two (2) program volunteers escorted the child down the hallway and into the care of teacher of a different preschool classroom. This was all confirmed in a review of the program video feed. The staff and children of the child's preschool group had left the property for a walk. This is a serious violation of supervision warranting a parental notification letter.

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7.7.5.1 · The licensee shall comply with background checks for these volunteers as required in the rule 3.2.6, and in the rules in section 7.2 of these regulations.

It was confirmed that the two (2) program volunteers who found the child unattended in the hallway on 03/06/2026, had not completed the required record check authorization form. Each person had been present more than five (5) times in the program and was required to have initiated the background clearance process before 03/06/2026.

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6.2.6.1 · Staff shall be able to hear all children of pre-kindergarten age and younger at all times, shall be able to see the children with a quick glance, and shall be able to physically respond immediately.

The program self-reported an incident involving supervision that occurred on 03/17/2026. A preschool aged child was left alone in the Jellyfish classroom for approximately fourteen minutes. The program video feed for 03/17/2026, showed that while a child was in the classroom bathroom the two (2) staff and remaining children in the group dressed for outside play and then left the classroom. The child exited the bathroom, walked around the empty classroom, opened the door to the hallway, and then read books in the book area. One (1) of the staff members returned to the classroom, assisted the child with dressing for outside play, and escorted the child out of the room. This is a serious violation of supervision warranting a parental notification letter.

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7.2.2 · The licensee shall ensure that all new staff and auxiliary staff, prior to working with children in the CBCCPP; and any new individual designated as the representative of the licensee shall submit a Records Check Authorization form to the Division and shall submit to fingerprinting at a location designated by the Division after having received the Fingerprinting Authorization Certificate by the Division.

Nine (9) staff who have been employed for over two (2) months have not followed through with all aspects of their background clearances.

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3.4.7.3 · Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director shall maintain an up-to-date BFIS Quality and Credential Account. Documentation, verification of qualifications, and all annual professional development activities as specified in the rules in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

Out of thirty-seven (37) staff who have been employed for over six (6) months, fifteen (15) are missing items in their credential accounts in BFIS.

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7.1.2.2 · Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

The following staff's First Aid/CPR has expired prior to the date of this visit: Staff A and Staff B. The following staff are missing First Aid: Staff C. The following staff must complete both First Aid and CPR: Staff D, E, F, G, H, I, J, K, L, M, and N have not completed First Aid or CPR.

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7.1.3 · The licensee, in consultation with the program director, shall establish written program policies and procedures and provide these to staff and to auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations during an orientation training session approved by the Division prior to being left alone with children. Trainees under eighteen (18) years of age and other staff not left alone with children shall complete the orientation training within at least one (1) month of their first date of working with children. Complete written information and the orientation training session shall include: Basic knowledge of child growth and development; Routine and emergency health protection of children including health related exclusions; Safety and sanitation requirements including handling and storage of hazardous materials and disposal of bio contaminants; Positive behavior management; Supervision of children; Child accident and injury procedures including building and physical premises safety; Safe sleep practices; Administration of medication requirements; Emergency and evacuation requirements; Nutrition and food safety including prevention of and response to emergencies due to food and allergic reactions; Recordkeeping; Transportation and child passenger safety; Release of children; Respectful engagement of families; Preventing, recognizing, and reporting child abuse and neglect; including information about the signs and symptoms of sexual abuse, sexual violence, grooming processes, recognizing the dangers of child sexual abuse, and other predatory behaviors of sex offenders; Recognition of and response to the symptoms of common childhood illnesses; Preventing the spread of infectious disease; Providing developmentally appropriate activities and experiences for children; Inclusion of children with special needs; Guidelines for volunteers, partner staff, auxiliary staff, and business managers; Responsibility to comply with current applicable licensing regulations; Staffing requirements to include opening and closing; and Ensuring children have extra clothes and diapers available.

Eight (8) staff have not completed an approved orientation training.

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7.4.4 · All staff shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations. Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt.

A review of BFIS and staff records show that six (6) out of the twenty (20) staff who have been employed for over a year are missing some of their required annual professional development hours.

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6.2.6 · Supervision of Children Staff shall ensure visual supervision of children, except as allowed in rules 6.2.6.1-6.2.6.4 of these regulations.

A toddler left the classroom and was missing for more than five (5) minutes before classroom staff noticed the child was missing. Once it was discovered the child was missing, it took more than five (5) minutes to locate them in the building and the staff did not immediately call 911 as per the program's procedure when the child was determined to be missing and not found in the immediate vicinity of the classroom.

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5.8.3 · Staff shall create and file an incident report for each accident, injury or medical emergency that leaves a visible mark, or first aid has been administered, even when medical treatment is not required. An incident report shall include the name of the child, date, description of the injury or medical emergency, how it occurred, adult witnesses, first aid provided, and medical care required. The child's parent shall be provided a copy of the report at pick up that day. Serious injuries, animal bites and death must be reported to the Division as specified in the rules in section 3.2 of these regulations.

The child's parent reported that they did not receive a written incident report from the program after their child was injured and transported by an ambulance to the hospital. The program confirmed the incident report did not get sent to the parent as required.

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3.2.1 · Serious injury or death of a child: The licensee shall make a timely report to the Division of any injury or accident involving an enrolled child resulting in in-patient or out-patient medical or dental treatment or death. In the event of a death, a verbal report shall be made immediately followed by a written report within twenty-four (24) hours. In the event of an injury or accident resulting in in-patient or out-patient medical treatment, a verbal report shall be made within forty-eight (48) hours and the written report shall be made within five (5) business days.

A child was injured at the program and was transported to the hospital from the program for medical care. The Child Development Division was not notified within 48 hours and a written incident report was not submitted within 5 days as required by this rule.

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6.2.5.8 · Nurturing activities performed by staff, including diapering, toileting, feeding, dressing, and resting; shall be performed in a relaxed, reassuring and individualized manner that is developmentally appropriate and promotes the child's learning, self-help and social skills.

On 10/4/2021, Child X was in the loft area during rest time and was standing while pulling and pushing a nap mat covered in a sheet. The staff person said they were sitting on the top of the loft stairs next to Child X as the child was repeatedly pushing the mat into the right side of their body. The staff person said they were not looking at Child X as they do not like to call attention to undesired behaviors. Video footage shows Child X pulling on the sheet covered mat, when suddenly the mat is pulled away in the direction of where the staff person was sitting. This action causes Child X's body to fall forward quickly and break their arm.

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6.2.8.4.2 · In the event that the concerns cannot be resolved, written notice to the child's parent(s) is required with at least five (5) days' notice prior to expulsion.

A family was sent an email giving immediate termination of care without a written five (5) day notice as required.

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5.10.1.11.2 · No person in the CBCCPP shall use or be under the influence of alcohol or drugs while present at the CBCCPP. Medication prescribed by a physician or over the counter medication that does not impair the ability of staff to adequately supervise and care for the children may be taken.

Staff X admitted to using heroin at 1:00 am or 2:00 am on 1/13/2021 before taking prescribed methadone medication at 8:30 am followed by arriving at work at 9:20 am. Staff Y described Staff X's behavior in the classroom as not typical, couldn't keep eyes open, and having a hard time. Staff Y also described picking up a small waxy white packet on the classroom floor which had been dropped by Staff X. Staff Y examined the packet before returning it to Staff X. The packet was labeled Moon Walk using a red ink stamp. Staff X admitted that a used heroin packet had quite likely been picked up by Staff Y and returned to Staff X. Video footage showed Staff X's behavior in the classroom as nodding off repeatedly for several moments, swaying and staggering around the classroom, crouching down to hold Staff X's head in Staff X's hands while children moved around Staff X, and at one point Staff X's head hitting a cupboard door. Video footage also showed the packet falling out of Staff X's sweatshirt, and Staff Y picking it up and examining it. Staff X admitted to not being able to work and that Staff X shouldn't have worked on 1/13/2021. Staff Y and Staff Z acknowledged being very concerned about Staff X's behavior in the classroom and Staff X's inability to work with children on the morning of 1/13/2021. Staff Y and Staff Z also said they didn't report their concerns to the program director until two (2) hours after they first observed Staff X's behavior. The staff: child ratios only required two (2) staff in the classroom which meant that the program director could have intervened without delay had staff reported concerns sooner.

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