The licensee shall not interfere with, impede, deter, provide false information or cause another to do any of the aforementioned, or in any manner hinder the Department or its agent(s) in an investigation or inspection.

Licensee/Program Director Kim Litchfield stated in two separate conversations that monthly evacuation drills were being completed and documented. She verbally confirmed that the corrective action of two (2) monthly drills for January, February, and March 2026 were completed. Four (4) of the current staff confirmed that evacuation drills have not occurred and they were aware of the two per month expectation for January, February, and March 2026. The statements made by Kim Litchfield are not credible.

2.3.1.5 · Not corrected

The licensee shall maintain a current list of the licensee or designee, staff, auxiliary staff, and volunteers as in the rules in section 7.7.5 of these regulations, as applicable in BFIS. Any changes shall be reported through BFIS within five (5) working days of the change.

Staff B is listed as a substitute within the program's associated parties list. In email correspondence dated 01/12/2026, Licensee/Program Director Kim Litchfield listed Staff B as a substitute. It was confirmed during this visit that Staff B has working Monday-Friday full time hours with a group of children since October 2023. The position title needed to be changed from substitute to one of the other staff positions in Section 7.2 as of November 1, 2023. As of the date of this visit, Staff B needs to meet a minimum of Teaching Assistant (Rule 7.3.2.3). This is a repeat violation. Failing to maintain compliance to the requirements of this rule was cited on 12/01/2021.

3.4.7.5 · Not corrected

The licensee shall ensure that evacuation drills are conducted at least once a month, and children and staff are evacuated in under three (3) minutes. Licensees of a CBCCPP located within a public or independent school building may count a lock-down drill performed while the CBCCPP is in operation in place of a monthly evacuation drill with the CBCCPP children and staff and at least three (3) of the monthly drills conducted within 365 days shall be evacuation drills.

The licensee shall ensure that all staff have met ongoing background check requirements by submitting at least once every five (5) years a Records Check Authorization form to the Division and as required shall submit to fingerprinting.

Staff person A's fingerprint clearance is past the five year mark. The program was notified via the BFIS system on 04/03/2025 that this staff person needing to complete the five year renewal for fingerprint clearance. It was confirmed during this visit that Staff person A has not completed the fingerprint process.

2.3.9.3 · Not corrected

The licensee shall maintain a record of the date of each evacuation drill as required in the rules in section 3.7.2 of these regulations that includes the number of children and staff evacuated, time taken to evacuate, and notation of the drill conducted while children were sleeping or resting. Evacuation records shall be kept for two (2) years. When the CBCCPP counts lock-down drills as allowed in the rules in section 3.7.2 of these regulations, the licensee shall maintain a record of the date of each lock-down drill, the number of CBCCPP children and staff who participated, and note that the drill performed was a lock-down drill.

The documentation of emergency evacuation drills for January 2025 through December 2025 was not available for review. This is a repeat violation. Failing to have the required documentation for evacuation drills was cited 12/01/2021.

3.4.6.1 · Not corrected

Children shall be protected from the harmful acts of other children.

One (1) child in care between 9/7/2024 up to 3/10/2025 bit other children twenty-four (24) times. The program advised one (1) of the families in January 2025 whose child had been bit that a referral had been made to the Family Place to conduct an observation for further support with this matter. On 2/5/25 further correspondance with this family found that they had been advised the program was working with the child and family regarding the concern and that a referral had been made to the Family Place to have an observation completed. While on site at the program, the Director reported, when asked when the referral had been made to the Family Place reported March 5, 2025. Upon consultation with the Family Place they confirmed they received a call from the Director on 3/5/25 and advised them that written parental permission would be required to move forward; as of 3/25/25 that had not been recevied. The Family Place reported they had no prior referrals in January or February as reported to the family. The program did not seek outside supports or planning with the child known to bite to devise a plan to address the concerns, therefore failing to do so continued to put children in harms way.

6.2.6.5 · Not corrected

Staff's expectations of children's behavior and responses to children's behavior shall be appropriate to each child's level of development and understanding. Guidance shall be designed to meet the individual needs of each child.

While observing during the onset of rest time, Staff A was heard telling children multiple times to lay down on their mats, despite both children being spoken to were observed on their mats just not in a laying position. Both children were quiet and not disruptive. One (1) child was observed bumping their head, to which Staff A responded had they been laying on their mat that would not have happened. Staff A was also heard saying no to children six (6) times during a period under thirty (30) minutes and at no time was Staff A observed providing an explanation or alternative. Staff A also advised children they would need to get the Director if they didn't stop doing what she requested. A review of an incident report filed by Staff B and through discussion with Staff B, it was determined that they expressed to the family and to Licensing that the child who requested an ice pack due to bumping their arm and was denied one intentionally went to another peer so they'd be bit in order to get the ice pack originally requested.

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.

On 1/29/25 during outdoor play a child was able to leave the play area, access the deck and continue into the parking lot and proceed down the driveway within approximately fifty-five (55) feet from the road before being noticed by staff. The staff who observed the child notified the staff assigned to the child and continued to retrieve the child. It was determined that the gate from the playground to the deck was left open, and the gate to the parking lot was not latched. Since this occurred the program identified gates are now locked after drop off and remained locked until parent pick up begins. This is a SERIOUS VIOLATION.

6.2.6.1 · Not corrected

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 violation was cited to this rule on 8/27/24 for the Director not completing the required fifteen (15) hours of annual professional development. Corrective action was due on 10/3/2024 that required the following: Create a system for tracking all staff annual professional development review periods and hours completed to ensure compliance. Submit a plan for Staff A to complete the missing four (4) hours from their previous period to their current period of 8/25/24 thru 8/25/25. On 11/22/2024 an email was sent to the Director to obtain the overdue corrective action with a deadline of 12/2/24. As of 1/10/2025 the corrective action had not been received.

7.4.4 · Not corrected

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.

Review of BFIS account and staff files on site, as well as follow up email correspondance determined Staff A to have only completed nine (9) of the fifteen (15) required annual professional development hours. Staff A's annual period reviewed was 8/25/23 thru 8/25/24.

7.4.4 · Not corrected

Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

Determination from interviews, Staff A reportedly does not allow children the opportunity to self-regulate and participate in tasks that allow for self-control and cooperation. Staff A reportedly physically assists children by walking them to the next location or task requested rather than allowing them to do so on their own.

6.2.7.3 · Not corrected

Staff shall appropriately hold, touch, smile and talk to children.

Determined through interviews, Staff A reportedly becomes frustrated with children and uses a harsh tone when speaking to them.

6.2.5.2 · Not corrected

The program director shall consult with the child's parent(s) and professionals, as appropriate, to develop and implement a plan to address concerns, with the goal of continuing the child's enrollment.

Three (3) children were expelled from the program without a plan to adequately address any concerns. Two (2) days prior to the expulsion the family was notified of concerns the program had and was asked to advise what the plan was for their children attending during the summer, and for the youngest child their plan to continue into the the fall. The communication discussed updating contracts, and stated for the family to reach out if they had questions or would like to discuss anything further. The contact made on 6/29/2022 did not indicate that care was at risk of ending, nor did it state a meeting was being requested to discuss the concerns. Two (2) days later the family was provided a termination letter.

6.2.8.4.1 · Not corrected

Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

Child A was required to wear a mask due to spitting; staff confirmed other children were not required to wear a mask when they spit. Requiring children to wear a mask due to spitting does not encourage self-control, self-direction, self-esteem, and cooperation.

6.2.7.3 · Not corrected

When violations are found to exist, the Division will offer the licensee the opportunity to develop a program improvement plan whereby the violations will be corrected within a time period mutually agreeable to the Division and the licensee.

The program was required to submit a program improvement plan to the Division due to non-compliance cited on 11/02/2021 to rule 6.2.7.3. On 3/11/2022 the Division found that the program did not meet the program improvement requirement and was cited in non-compliance to rule 2.4.1. The program had until 04/18/2022 to submit and implement their program improvement plan. A follow up visit was conducted on 05/25/2022 and found that the program improvement deadline was not completed, and portions of the program improvement plan were not implemented and followed. The behavioral reports used to document concerns with children were not implemented until the middle of May 2022. The program was required to create a procedure on how staff will receive immediate and ongoing support during the times childrens behaviors are challenging, to include staffing, breaks, time to document behaviors, and debriefing on what works, does not work, and next steps. Staff were not observed seeking assistance when needed, and the program has not documented that staff debriefing has occurred to discuss what is or is not working. By 04/11/2022 all staff should have completed the Basic Specialized Care training and submit that documentation to Northern Lights at CCV upon completion. The program stated that all staff will have completed this by 6/7/2022; which did not occur. Northern Lights at CCV confirmed that four (4) staff did not register until 6/7/2022, the course was not available next until 8/2022. Recommendations have been given to the program to better support staff and to reduce challenging behaviors from children; the program has not implemented those recommendations to include: posting the schedule for the day, providing more outdoor play items, providing children with a prompt that they are going to be transitioning, labeling items so that children can more easily take care of toys, designing the classroom to reduce open space for running, providing children with options after finishing snack rather than having them sit and wait for everyone to be done, and creating bathroom breaks in the schedule. These recommendations were not observed in practice. Follow up with the Family Place has not occurred to discuss observations and recommendations from the two (2) most recent visits. This is a repeat violation.

When violations are found to exist, the Division will offer the licensee the opportunity to develop a program improvement plan whereby the violations will be corrected within a time period mutually agreeable to the Division and the licensee.

The program was required to submit a program improvement plan to the Division due to non-compliance cited on 11/02/2021 to rule 6.2.7.3. A plan was provided stating that the program would request The Family Place to do observations of the classrooms to provide feedback to the Director and to train staff on appropriate interventions to challenging behavior, that the Director and the Family Place would create a policy/procedure related to challenging behaviors with children to ensure timely and appropriate actions are taken, and that staff would take additional trainings related to challenging behaviors. Follow up to determine the implementation of the plan found that observations were completed by the Family Place but that the Director had not met with them to receive feedback nor did the Family Place work directly with staff to provide suggestions on addressing challenging behaviors, the policy/procedure was not created, and the Director was uncertain which staff, if any had completed trainings they suggested to them.

2.4.1 · Not corrected

The licensee shall ensure that there is a sturdy diaper changing area with a clean, washable and non-absorbent surface. The diaper changing area shall not be located in the kitchen or any area where food is stored, prepared or served.

The diaper changing mat located in the bathroom near the toddler and preschool classroom has a tear in the middle exposing the interior foam. Staff B was observed changing a child on this mat.

5.2.3.4 · Not corrected

All interior and exterior walls, roofs, chimneys, floors, doors, ceilings, windows, skylights, stairways, ramps, and porches shall be maintained in good repair.

Nine (9) floor tiles were observed with cracks or sections missing. The bathroom next to the preschool classroom had exposed sheetrock, and outside the bathroom there are four (4) dime size holes in the wall. In the hallway from the kitchen to the toddler classroom, there is a section of baseboard missing. The door in the hallway next to the preschool classroom, leading to outside has chips in the wood trim. A board is peeling away from the wall in the toddler classroom. Vinyl siding is cracked and collecting dirt and debris; this is located on the ramp going to the outdoor play area from the infant room main entrance.

5.10.4.5.2 · Not corrected

The licensee shall develop and maintain a written Emergency Response Plan to respond to a full range of emergencies both natural and man-made. A complete plan shall include how the licensee will address and manage the following situations and responsibilities: Evacuations or other emergencies such as leaving the premise and lockdown situations; Specific concerns related to the location of the program, such as proximity to a nuclear reactor, an area prone to flooding or power loss; Notifying the local authorities of the emergency; A system for notifying the parents of the emergency; Notifying the local emergency planning committee regarding the location of the CBCCPP and using the committee as a resource in emergency planning for the program; A system of identifying the children and staff present at the time of the emergency and maintaining knowledge of their whereabouts; A system for handling infants, toddlers, and children with special needs; An established evacuation meeting location within walking distance of the CBCCPP; A system to account for all children and staff at the evacuation meeting place; A process for relocation if necessary, including safe transportation; A system for shelter in place if the staff and children present need to remain in the CBCCPP for an extended period; and Staff chain of command and individual staff roles and responsibilities, (if applicable) during emergencies.

When a child is expelled from the program, a full copy of the child's file must be provided to the child's parent(s) on or before the child's last day in the program. The CBCCPP shall retain documentation that the file was provided to the parent.

Child B was terminated from care effective 11/17/2021. As of 12/07/2021 a copy of the file had not been provided to Child B's parent.

6.2.8.4.3 · Not corrected

Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

Upon interviews with staff, it was confirmed that children are physically removed from places or situations by being picked up by staff. Staff confirmed that this often escalates behaviors, with children flailing their bodies, kicking, and screaming. Staff A confirmed that they had poked a child in the eye one (1) time when they were holding on to the child as the child attempted to bite them.

6.2.7.3 · Not corrected

Children two (2) years of age to school-age experience shall experience frequent positive interactions with a consistent staff member or team that provides each child with the following opportunities throughout the day: Face to face interaction; A combination of individual, small group, and large group experiences; Conversation with adults and peers during play, eating, and routine care; Being read to and looking at books, individually and in a group; Space and equipment to support developing gross motor skills such as catching and throwing, balancing, jumping, climbing, running, and skipping; Space and materials to support developing small motor skills such as using manipulatives, scribbling, drawing, and writing; Materials, experiences and support for developmentally appropriate pre-literacy and literacy skills; Materials, experiences, and support for developmentally appropriate mathematical and scientific concepts; Open-ended play and activities; Positive recognition of efforts, not just results; Developmentally appropriate problem solving; Materials, time, and encouragement to engage in extended and complex play alone and with peers; Experiences that promote social competence and cooperative play; Encouragement to explore, experiment and initiate activities; Developmentally appropriate independence; and Time, space, and encouragement to gain mastery through play and learning by doing.

Upon interviews with staff it was shared that children are moved from one (1) group to another group for reasons such as: behavior, staff needing a break, and to clean the program. Upon review of attendance sheets, it was noted that children are moved sometimes two (2) to four (4) times a day between classrooms.

Staffing Schedule: A licensee shall maintain a written record of the daily schedule for at least 365 days of all staff including exact days and hours worked and the group of children to whom they are assigned.

Upon arrival on 07/29/2020, Staff A and Staff B were present and counted in ratio in the walking infant room. An immediate review of the staff log reflected that both Staff A and Staff B were signed into the walking infant room. Staff A left the walking infant room at approximately 2:45 PM, and Staff C began working in the walking infant room. At 3:00, a review of the staff log reflected that Staff A was still in the walking infant room. Staff C did not have a profile in the staff logging system and therefore was not reflected at all on the staff log. Upon arrival at the program at approximately 1:45 pm, Staff C and Staff D were present in the preschool room. An immediate review of the staff log reflected that neither Staff C or Staff D were signed in to the preschool room. Further, the program director and multiple staff members stated that the program director was not in the building between the hours of 9:00 and 11:30 AM on 07/29/2020, however the staff log reflects that the program director was present and counted in ratio in the walking infant room throughout that time period.

3.4.6.5 · Not corrected

The licensee shall ensure that no person shall be left alone with children without approval from the Division which shall be based on the results of the background check to include fingerprinting.

The program director confirmed that several staff were left alone with children on multiple occasions prior to completing the fingerprinting process between March and July 2020. On 07/31/2020, Staff E confirmed that Staff E was working alone with a group of children for the day. A review of Staff E's BFIS quality and credential account confirmed that Staff E had not yet completed the fingerprinting process.

7.2.4 · Not corrected