3.4.5.1 · A licensee shall maintain a complete and up-to-date personnel file for staff working at the CBCCPP. A complete file shall contain, at minimum, the following information: Name, date of birth, home address and telephone number; Copies of current first aid and CPR certification; Signed statement verifying understanding of legal requirement to report suspected child abuse and neglect; Documentation of a current Records Check Authorization form; Documentation of having read and having ready access to a current copy of applicable child care licensing regulations; Administration of Medication training certification (if applicable); Signed statement verifying current job title and supervisor's name; Application for employment including references or reference checks; Employment start date; Documentation of completed orientation Training; Employment end date; IPDP (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt); and Written annual performance reviews (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt).

Staff files were not available on site, nor was an affidavit per rule 3.4.5.4 available.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

5.6.2 · The program director shall ensure that only staff, who have completed a training course approved by the Division, administer medication in the CBCCPP. With written parental permission, a school age child may self-medicate under the direct supervision of staff who meets the training requirement within this rule.

Children had medication on site to include emergency medications, however staff on site either had not 1) completed a medication training approved by the Divsion, or 2) submitted documentation of their training to Northern Lights at CCV to confirm it meets training requirements.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

6.2.6.3 · When children are eating, staff shall be positioned to allow for visual supervision of all children and shall be able to physically respond immediately to any child that may be choking.

During the licensing visit while children were eating, staff were observed moving around the room addressing children's needs in lieu maintaining visual supervision required by this rule.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

5.10.1.1.1 · The licensee shall ensure that children are protected from electrical outlets, such as by using protective covers, tamper-proof outlets, or other devices manufactured for this purpose.

Outlet covers throughout the space used by children did not meet compliance with this rule.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

5.10.1.1.2 · Children shall be protected from choking hazards presented by cords on window coverings, electric or electronic appliances or equipment and telephones.

During this licensing visit there were cords accessible to children presenting several areas of hazard to children.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

3.7.1.2 · The licensee shall ensure that all staff are trained on the Emergency Response Plan and are aware of where to find the written plan in the CBCCPP.

When asked, the Director indicated they had not been trained on the Emergency Response Plan and was not aware of the location of the written plan.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

3.7.2.1 · The licensee shall have a written evacuation diagram with evacuation routes posted in each classroom that is used by the children.

The written evaucation diagram was not posted as required by this rule.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

Director and Staff A were present working in the program without a record check having been submitted to the Division. The Director has been employed in the position since 8/21/25, and Staff A since 8/22/25. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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).

During the licensing visit the program was operating with three (3) groups; one (1) of those groups did not have any staff present who had been cleared through the background clearance process to include fingerprinting. Additionally, the Director who has not been cleared, was observed taking children inside alone to go to the bathroom. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

During the visit Staff A was the only Staff Member assigned to the Red group. The Red group was made up of thirteen (13) children, to include three (3) preschool age children, which would require a 1:10 ratio. This is a serious violation that requires a Parental Notification Letter (see rule 2.8.2).

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

During the licensing visit Staff B was observed on their cell phone leaning up against a fence for a minimum of four (4) minutes while children were playing. During this time supervision was not maintained of children to see them with a quick glance or be able to respond immediately. Children were also observed running out of the classroom and when asked how many children had left the room Staff C was unable to state how many.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

3.4.1 · The licensee shall keep all required records, schedules, materials, and equipment used to operate and maintain the CBCCPP in good order and in locations appropriate for day to day access.

When requested to view evidence of continuous insurance, staff files, children files, emergency response plan, and evacuation records, the Director was unable to access those while on site. The program was requested to provide documentation by 9/4/25 at 12:30 PM; access to children's files was not provided until 9/10/25, were not in organized files, but rather indendent pages not directly linked to each individual child who is enrolled. The emergency response plan was not received until 9/12/25.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

Upon review of staff BFIS Quality and Credential accounts it was determined that compliance to this rule was not met.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

It was determined at this visit that several staff were listed in position titles they were not serving in. The program did not notify the Division of this change nor submit updated record checks to capture this change. In addition, a minimum of four (4) staff members were listed on the Associated Parties list who the Director identified were no longer employed by the program. This is a repeat violation.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

2.3.11.1 · The official posted license shall contain and display the following: * Status of the license: full or provisional; * Effective date of the license; * Expiration date of the license; * The maximum number of children who may be served at one (1) time; * The ages of the children who may be served; * The applicable type of regulated service for which authorization to operate has been granted; * Terms and/or conditions added to the license; and * Approval to prepare and provide meals if granted.

The license was not posted as required by this rule.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

2.3.12 · Changes that Impact a License The licensee shall notify the Division prior to any of the following changes in the operation of the CBCCPP. The Division shall determine whether it will be possible to modify a current license, approve a time limited variance or if the licensee must submit an application for a new license: * A reduction, addition or substantial change in the indoor or outdoor spaces utilized for the care of children in the CBCCPP; * A change in the name of the CBCCPP; * A change in the CBCCPP's Taxpayer Identification Number; * A change in the authorized license type of regulated service as defined in these rules; * A change in the number of children the CBCCPP serves at any one (1) time; * A change in the ages of children the CBCCPP serves; * A personnel change designating a new/different program director; or * A change naming a new designated representative for the licensee.

At the licensing visit it was determined the Director began on 8/21/25 but a change in Director notice had not been submitted as required by this rule. In addition it was determined that the governing bodies submitted with the application is no longer current.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

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.

At the time of the licensing visit, five (5) staff required to take this training had not done so.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record

5.11.8.4 · As long as appropriate documentation is provided, staff shall consistently accommodate special nutritional requests and restrictions from parents. Staff shall know and accommodate children's food allergies.

It was determined though children on site have allergies requiring the administration of on-site medication, staff on site were unaware of this.

Open Not marked corrected in the state record

Open / not marked corrected.

View state record