Alicia Bethel

Regulation 5.10.1.8: Childhood Lead Poisoning Prevention The FCCP shall comply with the requirements of 18 V.S.A. Chapter 38 Vermont Lead Law and shall ensure that Essential Maintenance Practices (EMP) is performed. This includes but is not limited to protecting children from peeling or chipping paint, and dust build up from the friction of moving doors or windows.

“Upon review of of the Vermont Department of Health's database for IRC compliance, it was identified that and IRC compliance statement had not been filed since 11/20/2023. No evidence stating otherwise was presented by the Provider. Corrective Action: Immediately ensure that IRC practices are conducted and an IRC compliance statement is filed with the Vermont Department of Health. Develop a system to ensure that IRC practices are conducted annually moving forward to include filing the compliance statement. In the corrective action email provide a copy of the IRC compliance statement and details of the system developed to ensure compliance moving forward.”

Correction date in the state record: Jan 12, 2026

Regulation 5.10.1.1.1: The FCCP 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.

“An electircal outlet next to the television and an extension cord beneath the dining room table were both observed accessible ot children with no protective coverings. In addition, a power strip was observed on the floor next to the couch, which also did not bear protective coverings. Corrective Action: Immediately ensure that all electrical outlets are made inaccessible to children. In the corrective action email provide photo evidence of how the identified electrical outlets have been made inaccessible.”

Correction date in the state record: Jan 12, 2026

Regulation 7.4.4: All staff, with the exception of substitutes, shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations.

“A violation to this rule was cited on 12/04/2024 with a corrective action due date of 01/15/2025. An email was sent to the program on 06/17/2025 requiring all outstanding corrective action to be completed by 06/24/2025. The original corrective action required that the Provider complete five (5) hours of professional development and submit completion certificates to Northern Lights for entry into their BFIS account with Jessica.Stannard@vermont.gov copied on the submission email(s). These five (5) hours are in addition to the required annual fifteen (15) hours. As of 06/25/2025 no confirmation of any hours of professional development being completed has been provided to the Division. This is a repeat violation. Corrective Action: Complete five (5) hours of professional development that were not obtained between 07/03/2023-07/03/2024. Ensure that you are also on track to obtain the required fifteen (15) hours of professional development needed between 07/03/2024-07/03/2025. By 07/09/2025 submit certificates of completion verifying that the lacking five (5) hours have been completed to Northern Lights at CCV with Jessica.Stannard@vermont.gov copied on the submission email. In the corrective action email, provide details of the plan to ensure compliance with this rule will be maintained moving forward.”

Correction date in the state record: Jun 27, 2025

Regulation 7.4.4: All staff, with the exception of substitutes, shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations.

“Ten of 15 required professional development hours are documented in BFIS. Provider stated that these were all of the completed hours. Corrective Action: By 01/15/2025, complete 5 hours of professional development and submit completion certificates to Northern Lights for entry into your BFIS account. Copy Jessica.Stannard@vermont.gov on the email(s). Additionally, ensure that 15 more hours of professional development are completed by 7/3/2025 to meet the next year's requirement. These hours will be reviewed at the time of the next compliance visit.”

Correction date in the state record: Jun 27, 2025

Regulation 5.1.2: General Health Examinations: Within forty-five (45) days of enrollment the FCCP shall obtain documentation of the child's age appropriate well care exam from the parent. Documentation shall include information regarding any health conditions and medications that may impact the care of the child.

“Of the five (5) files reviewed, three (3) of them were missing the required health exam. Corrective Action: Ensure each child has a health exam on file. Develop a system to ensure this is obtained within forty-five (45) days of enrollment.”

Correction date in the state record: Feb 9, 2023

Regulation 3.3.4.2: Each child's file shall be complete with all required information within the first week that the child begins to attend care. The required annual physical shall be obtained within forty-five (45) days of enrollment as required in rule 5.1.2 of these regulations.

“Child A did not have registration form on file indcating the child's address, parents address, phone numbers, emergency contacts, authorized pick up, nor permission to seek medical care upon emergency. This is a repeat violation. Corrective Action: Ensure a complete file is on site for Child A on the next day they attend or by the stated due date, whichever comes first. Submit a program improvement plan on how children's files will be obtained prior to attending, and how they will be checked to ensure all required documents are on file and all signatures obtained.”

Correction date in the state record: Feb 9, 2023

Regulation 5.10.1.14.4: Animals shall not be allowed on surfaces where food or drink is prepared or served. Animals who roam freely shall not be allowed near children who are eating.

“Two (2) cats were observed on the counters prior and during food prep. Corrective Action: Ensure cats are not in on surfaces used for food preparation and service during the time this is occurring. Ensure that the areas where food is prepped and served are sanitized prior per rule 5.2.6.5. The provider did not sanitize the surface before or after.”

Correction date in the state record: Feb 9, 2023

Regulation 7.1.2.1: The FCCP shall have successfully completed pediatric first aid and CPR prior to being licensed and must remain currently certified.

“First Aid was not renewed by the Provider or their substitute, and currently neither are certified. Corrective Action: Ensure the Provider and substitute complete a First Aid training by the due date.”

Correction date in the state record: Feb 8, 2023

Regulation 5.2.3.4: The FCCP shall ensure that there is a sturdy diaper changing area with a clean, washable and non-absorbent surface. The diapering changing area shall not be located in the kitchen or any area where food is stored, prepared or served.

“Provider A showed the diaper changing mat that is used. There was one (1) tear on the mat approximately one (1) to two (2) inches long. Corrective Action: Repair or replace the diaper changing mat to ensure it is washable and non-absorbant. Develop a system that monitors the diaper changing pad to ensure it is repaired or replaced if the non-absorbent surface is compromised.”

Correction date in the state record: Apr 13, 2022

Regulation 3.3.3: The FCCP shall establish a system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the FCCH. The FCCP shall save all daily attendance records identifying the hours of children s attendance for at least twelve (12) months from the date that care is provided.

“Attendance records were provided which reflected that the last time attendance was documented was the week of January 24th-January 28th. Provider stated that she has not documented attendance since then. Corrective Action: Effective immediately ensure that childrens actual arrival and departure times are documented. Submit a program improvement plan that ensures that attendance will be promptly documented when children arrive and leave for the day, and that the attendance documents are maintained as required by this rule.”

Correction date in the state record: Apr 13, 2022

Regulation 3.3.6.1: The FCCP shall maintain a record of the date of each evacuation drill as required in the rules in section 3.6.2 of these regulations that includes the number of children, 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.

“The last evacuation drill logged was June 3, 2021. Provider stated that they have been doing the drills but have not kept up on the documentation. This is a repeat violation. Corrective Action: Submit a program improvement plan that identifies the system to promptly document drills once completed, and to maintain that documenation as requierd by this rule.”

Correction date in the state record: Apr 14, 2022

Regulation 5.4.1.4: Cots, mats, and mattresses shall be nonporous or have nonporous coverings. Each child shall be provided clean, individual bed linens either by the FCCP providing them or requiring parents to provide them. No child shall nap directly on nonporous coverings.

“Three (3) of the five (5) nap mats were observed with tears and fraying on the ends and sides. This is a repeat violation. Corrective Action: Repair or replace the torn and frayed nap mats. Develop a system that ensures that the condition of the nap mats are monitored and remedied if they are compromised to ensure compliance to this rule. Provide pictures of the repaired mat, or receipts to confirm new mats were purchased if this is the case.”

Correction date in the state record: Apr 14, 2022

Regulation 5.10.1.2.5: There shall be at least one (1) easily accessible dry chemical fire extinguisher which has at least a 2-A: 10BC classification. This fire extinguisher shall be maintained in operating condition. It shall bear an official tag, properly signed, attesting to current operating condition.

“The fire extinguisher onsite was a 1-A:10-B:C; this does not meet the requirement as stated by this rule. This is a repeat violation. Corrective Action: Ensure a fire extinguisher is on-site that meets the classification as stated in this rule. This extinguisher shall be inspected and tagged, or if purchased new have a receipt taped to the extinguisher reflecting the purchase date.”

Correction date in the state record: Apr 12, 2022

Regulation 5.10.1.10.3: All poisonous or toxic materials shall be inaccessible to children.

“Under the kitchen sink were items that are toxic and/or poisonous to children, to include: window cleaner, Lysol spray, granite cleaner, aerosol sunscreen, carpet cleaner, oil soap, all purpose cleaner, and laundry stain remover. The doors had child locks on them but they were not latching to prevent children from accessing those items. This is a repeat violation. Corrective Action: Repair or replace the child-proof locks under the kitchen sink, or remove the hazardous items to ensure children do not have access to the chemicals stored beneath. Submit a program improvement plan that identifies how hazards will be monitored and that children do not have access to hazards to include checking locking mechanisms to ensure proper functioning.”

Correction date in the state record: Apr 14, 2022

Regulation 3.3.4.2: Each child's file shall be complete with all required information within the first week that the child begins to attend care. The required annual physical shall be obtained within forty-five (45) days of enrollment as required in rule 5.1.2 of these regulations.

“Upon review of childrens files, Provider stated that they did not have a file for Child A. Corrective Action: Ensure all children currently enrolled have a complete file. Develop a system that ensures upon enrolling new children that they attend only after the required documentation has been obtained.”

Correction date in the state record: Apr 12, 2022

Regulation 5.10.1.2.6: The extinguisher shall be visibly mounted to the wall near an exit door.

“The extinguisher was not mounted as required by this rule. It was behind items on the floor near the exit. Provider acknowledged they knew the extinguisher was required to be mounted. This is a repeat violation. Corrective Action: Ensure that the extinguisher is mounted by an exit door as required by this rule. If the mount needs to be taken down due to house repairs, ensure that the extinguisher is re-mounted while children are in care, or moved to a different exit to be mounted.”

Correction date in the state record: Apr 14, 2022

Regulation 3.3.4.1: The FCCP shall maintain a complete and up-to-date enrollment file on-site for each child enrolled in the FCCH. A complete file shall contain, at minimum, the following information: * A completed child's admission form signed and dated by the parent that includes the first date the child attended the FCCH and the days and hours the child is regularly scheduled to attend the FCCH; * The child's name, current home address and current home telephone number; * The child's date of birth; * Name, address and all applicable current telephone numbers for parents; * Name, address and all applicable current telephone numbers for at least two (2) other people designated by the parents as emergency contacts; * Names for all persons authorized to pick the child up from the FCCH; * Record of an annual physical and health history as required in the rule 5.1.2 of these regulations that includes the name and telephone of the child's primary health care and dental care providers (if the child has a dental care provider); * A description of any special medical, developmental, emotional or educational needs of the child including allergies, existing illnesses or injuries, previous serious illnesses or injuries and any prescribed medication including those for emergency situations; * Written authorization from the parent for the FCCP to be able to obtain emergency medical care and transportation; * Child's immunization record or Vermont Department of Health approved exemption document as required in the rules in section 5.1.3 of these regulations; * Written permission from parents for the FCCP to transport the child, if transportation is provided, as required in section 5.10.6.6.1 of these regulations; * Written permission from parents for child to participate in swimming activities, if swimming activities are a part of the program, as required in the rule 5.10.5.1 of these regulations; * If applicable, a copy of court orders on custody and visitation arrangements as required in the rule 3.5.4 of these regulations; and * If applicable, any obvious injuries discovered and documented on daily health check as required in the rule 5.3.2 of these regulations.

“Upon review of children's files, there was a file missing for Child A. In review of five (5) other files, all were missing a health exam, the child's address, dentist, and addresses for emergency contacts. Two (2) children did not have immunizations, emergency contacts, or authorized individuals for pick up. A schedule and date of enrollment was missing in one (1) file. Corrective Action: Ensure children's files have each required component, and submit a program improvement plan identifying how children's files will be maintained.”

Correction date in the state record: Mar 16, 2020

Regulation 5.10.1.2.5: There shall be at least one (1) easily accessible dry chemical fire extinguisher which has at least a 2-A: 10BC classification. This fire extinguisher shall be maintained in operating condition. It shall bear an official tag, properly signed, attesting to current operating condition.

“When asked to see the fire extinguisher, Provider A showed a tagged extinguisher, however the tag had expired in 2017. Corrective Action: Submit a program improvemet plan to maintain a valid fire extinguisher on site at all times.”

Correction date in the state record: Mar 8, 2020

Regulation 6.2.3.5: The FCCP or at least one (1) staff member shall sit with children during meals and snacks.

“Observations were made of children eating lunch. During the duration of this time, Provider A did not sit with children at any time. Corrective Action: Provider A shall sit with children while they are eating.”

Correction date in the state record: Mar 10, 2020

Regulation 5.10.1.2.6: The extinguisher shall be visibly mounted to the wall near an exit door.

“When asked to see the fire extinguisher, Provider A retrieved the extinguisher from behind cleaning products in the cabinet beneath the sink. Corrective Action: Maintain a mounted fire extinguisher near an exit at all times.”

Correction date in the state record: Mar 8, 2020

Regulation 5.10.1.10.3: All poisonous or toxic materials shall be inaccessible to children.

“In the bathroom, and accessible to children, was hydrogen peroxide, lotions, soap, and shampoo. In the kitchen under the sink, there were cleaning solutions including 409, bleach, cascade pods and woolite. Provider A stated that the latches fell off two (2) weeks ago. Corrective Action: Ensure all items indicating to keep out of reach of children, are inaccessible to children at all times.”

Correction date in the state record: Feb 22, 2020

Regulation 5.4.1.4: Cots, mats, and mattresses shall be nonporous or have nonporous coverings. Each child shall be provided clean, individual bed linens either by the FCCP providing them or requiring parents to provide them. No child shall nap directly on nonporous coverings.

“Provider A showed the pack and plays and mats that children use during rest. Three (3) of the four (4) nap mats were torn along the seams, exposing foam. Corrective Action: Submit a program improvement plan to ensure that mats used for rest are intact and nonporous.”

Correction date in the state record: Mar 9, 2020

Regulation 5.10.4.5.6: Exterior stairs, walks, ramps and porches shall be cleared of ice and snow or other environmental hazards that may block exits.

“The program has three (3) exits from the building. The front door was blocked internally by infant equipment. The exit from the downstairs bedroom was blocked internally by a chair, and externally by totes and other unidentified items. The side door closest to the driveway had a trash bag hanging on the handle, which resulted in the door opening only partially. Corrective Action: Ensure that atleast two (2) exits are clear at all times that children are in care.”

Correction date in the state record: Mar 16, 2020

Regulation 3.3.6.1: The FCCP shall maintain a record of the date of each evacuation drill as required in the rules in section 3.6.2 of these regulations that includes the number of children, 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.

“Provider A provided the fire drill record upon request. A fire drill was last documented to have occurred in September 2019. Corrective Action: Submit a program improvement plan to ensure that monthly evacuation drills are conducted and fully documented as required by this rule.”

Correction date in the state record: Mar 16, 2020

Regulation 5.10.1.1.6: The FCCP shall ensure that sharp objects are kept out of children's reach unless used for a planned activity and closely supervised by an adult.

“In the kitchen area there were sharp knives on the stove, and in drawers. The knives were within reach and accessible to children. Children were observed going between the kitchen and play area throughout the duration of the visit. Corrective Action: Ensure all sharp objects are kept out of children's reach.”

Correction date in the state record: Feb 10, 2020

Regulation 3.3.7.3: Within six (6) months of initial date of employment, the FCCP and all staff 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 sections 7.3 and 7.4 of these regulations shall be submitted to NLCDC to be verified and maintained in BFIS.

“Upon review of quality and credential accounts within BFIS, it was found that Provider A did not have documentation of her education. Provider B also did not have documentation of education in his quality and credential account. Provider A & B did provide documentation post visit. Corrective Action: Submit all documentation of Provider A & B's qualifications and professional development certificates to Northern Lights as required by this regulation. Develop a system to ensure future documentation is submitted to Northern Lights to maintain an up-to-date BFIS quality and credential account.”

Correction date in the state record: Mar 5, 2020

Regulation 2.3.10.5: The FCCP shall be responsible for compliance with all applicable state and federal laws even when they are more stringent than the rules in this set of FCCH regulations.

“Provider A & B's CPR/First Aid certificates were requested. Provider A stated that Provider B was not CPR/First Aid certified, and was unaware that Provider B needed to be. Provider A was advised that a memo was sent out in July 2019 from the Division advising of the change in CPR/First Aid requirements. Provider A stated that she completed her CPR/First Aid certification online but did not do a in person skills assessment as she wasn't aware she needed to. Corrective Action: Provider A & B shall obtain CPR/First Aid certification approved by the Child Development Division, and maintain the certification while employed at the program.”

Correction date in the state record: Apr 6, 2020