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.

This is a repeat violation. A violation to this rule was cited on 03/19/2025 with a corrective action due date of 04/18/2025. The original corrective action required the program to submit documentation to Northern Lights at CCV using the cover sheet, and to ensure Licensor Sheldrick was CC'd on that email, as well as to create a system for ensuring all staff accounts are complete within six (6) months of hire as per this rule. An email was sent to the program on 04/04/2025 identifying the staff persons names and information needing to be submitted. As of 04/21/2025, the documents qualifications for three (3) of the staff persons were still not submitted. The documentation submitted as a follow up to this 04/21/2025 visit was missing the qualifications for these individuals. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

5.8.2 · Staff shall ensure that if an accident or injury occurs to a child, while in attendance, immediate action is taken to protect the child from further harm and notification of the child's parents as quickly as possible.

This is a repeat violation. The program was cited a violation to this rule during a site visit on 03/19/2025. The program was required to update the staff handook regarding the requirements for filing incident reports and notification to the family requirements. The due date for this corrective action was 04/18/2025. It was confirmed during this visit on 04/21/2025 that the required corrections had not been completed.

Open Not marked corrected in the state record

Open / not marked corrected.

2.8.1 · The licensee shall post site visit reports as directed, notices of violations, or notices of regulatory action for no fewer than fifteen (15) days following receipt by the CBCCPP in a place where the information is clearly visible to parents.

The program did not post the site visit report for the 03/19/2025 visit as required by this rule. It was confirmed that the site visit letter with violations noted was not posted within the facility either in paper form or upon the electronic notice board.

Open Not marked corrected in the state record

Open / not marked corrected.

6.2.1.3 · The program director shall ensure that the number of staff present meets requirements described in the chart below for ages of children, maximum group size, and staff/child ratios at any time of day.

This is a repeat violation. Seventeen (17) children ranging in age from twenty-three 23 months of age to thirty-six 36 months of age were present with two (2) staff persons during rest time. The number and ages of the children present required three (3) caregivers. The third (3) staff person was observed exiting the bulding to have their break outside.It was confirmed with staff persons present that no person was designated to replace this individual in the staff to child ratio during their thirty (30) minute break. Failing to maintain staff to child ratios during rest time was cited during a licensing visit on 03/19/2025. This is a repeat SERIOUS VIOLATION.

Open Not marked corrected in the state record

Open / not marked corrected.

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

This is a repeat violation. The program was cited a violation to this rule on 03/19/2025 with required corrective action due by 04/18/2025. Staff persons were required to complete a training through the Better Kid Care website titled "See as a Child, Feel as a Child". As of 04/18/2025, no staff persons had completed the training and staff persons asked about the requirement stated they were unaware of the requirement.

Open Not marked corrected in the state record

Open / not marked corrected.

6.2.1.3 · The program director shall ensure that the number of staff present meets requirements described in the chart below for ages of children, maximum group size, and staff/child ratios at any time of day.

Fifteen (15) children were with one (1) staff during rest time, to include a twenty-eight (28) month old child. One (1) additional staff within hearing distance indicated they had not been working in a classroom, rather doing Director duties, the other staff in the building was assigned to another group of children in a different classroom, and the final staff was on break outside of the building. This is a SERIOUS VIOLATION.

Open Not marked corrected in the state record

Open / not marked corrected.

6.2.6.6 · The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

Upon arrival to the program the two (2) operating classrooms each had staff alone with children who had not been cleared to do so. The Director confirmed that prior to our arrival they had not been in a classroom and had been conducting Director duties in the office. Upon review of previous weeks staff attendance in each classroom, it was found that staff were alone with children and were not cleared to do so in the Nido classroom on 3/3/25, 3/5/25, 3/6/25, and in the Casa classroom on 3/4/25. Additional days in each classroom found times throughout additional days that coverage was provided by staff not cleared to be alone with children. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

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 in care and required medical attention the same day. The program was aware the injury occurred on site, and that the child received medical attention. The program did not notify the Division as required by this rule.

Open Not marked corrected in the state record

Open / not marked corrected.

5.8.2 · Staff shall ensure that if an accident or injury occurs to a child, while in attendance, immediate action is taken to protect the child from further harm and notification of the child's parents as quickly as possible.

Upon review of video footage of 1/30/25 and through discussions with staff, a child was injured at 9:30 am. The child was observed holding their arm and was minimally engaged with their peers with use of only one (1) arm during play. Staff were observed acknowledging the child holding their arm at points during open play. The child's family was not informed of this injury until approximately five (5) hours after it occurred. The child required medical attention and this was delayed as a result of the family not being aware.

Open Not marked corrected in the state record

Open / not marked corrected.

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

Upon review of video footage from 1/30/25, Staff A is observed grabbing at Child B's upper right arm as Child B sat at table with their peers. Child B is observed pulling away from Staff A. Staff A is not heard speaking to Child B to request them to move, or to transition to another activity. Staff A is then observed grabbing Child B's left hand and pulling in an upward motion. Child B is observed falling to the ground and immediately is seen holding their left wrist and crying. Staff A is observed throwing their own hands above their head while Child B walks off screen to a different area of the room. Staff A is observed sitting in the chair and then approaching the area Child B went. Additional video footage showed Staff A taking food from a different child, and putting their lunch box away. There was no discussion about the child still eating or willingness to cooperate and move on to another activity. Throughout the review of video footage children were observed eating at their will; there was no explanation to this child why they were no longer able to eat, other than they stepped away from the table with food. The child was not re-directed or given a warning.

Open Not marked corrected in the state record

Open / not marked corrected.

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.

A review of BFIS and on-site files was done to assess staff qualifications related to a concern brought forward to the Division. Documentation required to be in staff quality and credential accounts was not in place for this assessment to be completed. Once the corrective action has been completed a focus compliance visit will be conducted to further assess the original concern that staff are not qualified for their positions.

Open Not marked corrected in the state record

Open / not marked corrected.

5.10.3.3 · Safe Use Zones For all play equipment that is thirty (30) inches or higher from the ground, including climbing equipment, slides, swings and other similar equipment, the licensee shall ensure that the surface under and around the equipment, including recommended use zones, is of approved resilient material that protects children if they fall. * Materials in the use zone shall consist of wood chips, pea stone, mulch, engineered wood fibers, sand, safety-tested shredded or rubber like material or rubber mats designed for protective cushioning; * Materials used in the use zone shall follow the recommendations listed in the most recent publication of U.S. Consumer Product Safety Commission's Public Playground Safety Handbook regarding critical depth of tested materials determined by the height of the highest climbing surface of the equipment; * Materials used in the use zone shall be installed and maintained according to the manufacturer's instructions; * If the loose material such as sand, mulch, or shredded rubber is used in use zones, the licensee shall ensure that the material is raked regularly and replenished to maintain depth and resilience; and * If the resilient material in use zones freezes, staff shall ensure that children will not play on the equipment until the resilient material has thawed and is once again resilient.

Inspection of the playground found the climbing dome did not have adequate cushioning material as required by this rule. Children were observed climbing on the dome, placing them higher than thirty (30) inches.

Open Not marked corrected in the state record

Open / not marked corrected.

3.7.2.2 · 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.

Conversation with Staff A determined drills were completed in June and July 2024, however not in August or September 2024. As the record of evactuation drills was unable to be located, it is unknown what drills were completed between October 2023 and May 2024.

Open Not marked corrected in the state record

Open / not marked corrected.

3.4.6.1 · 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.

Program was unable to provide evacuation drill records for the prior year.

Open Not marked corrected in the state record

Open / not marked corrected.

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.

Review of BFIS Credential accounts determined Staff D, Staff E, and Staff F, all identified during the visit as working being counted in ratio and/or left alone with children, had not yet completed this training. The three (3) staff have all been employed at the program for more than three (3) months. Credential review also revealed Staff B's certification expired 8/27/23, and Staff C's expired 12/31/21.

Open Not marked corrected in the state record

Open / not marked corrected.

3.3.5 · The licensee, staff, and auxiliary staff shall be trained in prevention, identification and mandatory reporting of child abuse and neglect.

Review of BFIS accounts for all staff as well as staff files on site, determined Staff E, Staff G, Staff H, Staff I, Staff J, and Staff K have not completed this required training.

Open Not marked corrected in the state record

Open / not marked corrected.

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.

During this visit Staff L, Staff M, and Staff N were present and working in the classrooms with the children although they are not on the program's Associated Parties list. It was also identified based on BFIS review that fingerprinting is outstanding for Staff A, Staff B, Staff D, Staff E, Staff F, Staff K, and Staff P. In addition, Staff E has not provided the Division with the required Out of State paperwork sent to them.This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

2.3.9.3 · 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.

Review of BFIS determined Staff O was due to complete new fingerprinting by April 2023. Staff O was advised of this in a letter generated and issued 3/15/23. Staff O submitted the required Records Check Authorization on 1/19/24 at which time a letter advising of fingerprinting was issued. As of this date fingeprinting for Staff O has not yet been completed

Open Not marked corrected in the state record

Open / not marked corrected.

6.2.6.6 · The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

At the time of this visit no staff members present have been cleared by the background check process. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

3.4.7.5 · 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.

Review of Associated Parties list with Staff A during this Licensor's visit determined list is not up to date as five (5) staff were identified as no longer working at the program as of the end of summer programming.

Open Not marked corrected in the state record

Open / not marked corrected.

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.

Staff A identified Staff B, Staff C, and Staff D as being the staff present in the Casa classroom. Staff A identified Staff Y and Staff Z as being present in the Nido classroom. Review of Associated Parties list as of 7/23/24 determined none of the five (5) staff identified by Staff A were on the list.

Open Not marked corrected in the state record

Open / not marked corrected.

6.2.6.6 · The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

Upon arrival at the program, Staff B, Staff C, and Staff D were observed to be on the outdoor playspace with a group of eighteen (18) children. Review of Associated Parties list determined none of these three (3) staff had been cleared by the Division's background check process. Staff A, the only staff member present who has been cleared by the process, was inside the building unable to see or hear the outdoor playspace.

Open Not marked corrected in the state record

Open / not marked corrected.

5.10.1.1 · General Safety: The licensee shall ensure the physical facilities of the CBCCPP, grounds, equipment, and toys present no hazard to the health, safety, and well-being of the children.

Department of Fire Safety as well as Staff A from the program identified and confirmed children were present at the same time construction was being done to expand the program's bathroom. It was confirmed the construction caused levels of dust resulting in the fire alarms going off. It was determined by DFS a increase in the carbon monoxide levels occurred due to the use of gas powered equipment, although they did not rise high enough to set the CO2 alarms off. Children were evacuated immediately upon the setting of the fire alarm.

Open Not marked corrected in the state record

Open / not marked corrected.