Boys & Girls Club at Benson

Regulation 5.14: 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.

“During a virtual Debrief meeting with the Site Director on 11/26/2024, it was identified that Staff B and C were currently the only two (2) Staff members working with children at the Program site for the day. Neither Staff B or C had received approval from the Division to be left alone with children. Director statements reflected that this had occurred more than once in the previous week. In addition, while on-site on 11/14/2024, Staff A was unaware that Staff B had not received clearance to be left alone from the Division. Staff A stated that there had not been a time when Staff B was left alone up to this point, but both Staff A and B were unaware of the requirements of this rule. Corrective Action: Immediately ensure that individuals who have not received approval from the Division are not left alone with children. In the corrective action email, provide evidence that individuals lacking approval are no longer being left alone with children. Develop a system to ensure that at least one (1) individual who has received approval from the Division will be present at all times moving forward.”

Correction date in the state record: Jan 10, 2025

Regulation 13.6: Staff shall follow the exclusion policies as set forth in the document Signs and Symptoms of Illness Chart (Adapted) which shall be made available to parents and Staff, and posted where parents and Staff can read it. (See Appendix A).

“The Signs and Symptoms of Illness Chart was not posted in the program. Corrective Action: Immediately post the Signs and Symptoms of Illness Chart (See Appendix A) where parents and staff can read it. Submit photo evidence of the posted policies to Licensor [name] via email.”

Correction date in the state record: Jan 10, 2025

Regulation 5.28: The Licensee is required to maintain an accurate record of Staff schedules and assignments for all Staff including substitutes.

“A staff schedule was not observed during the visit due to staff not having access. On 11/25/2024 the Site Director provided a Staff Schedule electronically. The schedule did not include the hours in which the Director is on site. The Director confirmed that there is no documentation recording when she is on site. Corrective Action: Develop a system to ensure that all Staff schedules and assignments are recorded accurately. In the corrective action email include details of the system developed to ensure compliance moving forward.”

Correction date in the state record: Jan 10, 2025

Regulation 18.77: Within six months of the initial date of employment, Staff working with children and the Site Director and/or Program Administrator 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 Section 5 of these regulations shall be submitted to NLCDC to be verified and maintained in BFIS.

“Upon review of Staff BFIS Quality and Crendential Accounts and provided electronic Staff files it was identified that nine (9) staff members were missing reflection of at least one (1) document in BFIS. All nine (9) staff members had been employed/working with children at the program for more than six (6) months. Corrective Action: Immediately plan to review all staff BFIS Quality and Credential accounts to update and accurately reflect all staff qualifications and annual professional development. By 01/10/25, submit documentation to Northern Lights at CCV with cover sheets and with Licensor [name] copied on the submission email. Develop a system to prompt submission of documentation to Northern Lights moving forward. In the corrective action email include details of the system developed to include 1. Who is responsible for regular review of, and submissions to, staff BFIS Quality and Credential Accounts and 2. How that person will be prompted to complete required submissions in a timely manner.”

Correction date in the state record: Jan 14, 2025

Regulation 10.9: Emergency evacuations shall be practiced with the children each month. A record of practice drills for the previous and current year shall be maintained and available onsite. Practice drills may be pre-announced. There shall be: * a system in place to assure that all children are accounted for at a predetermined safe place; * a safety plan that may include additional lock down practices and procedures.

“Staff statements reflected that documentation of evacuation drills is not kept. A record of one drill was observed on a small piece of paper. Only the date of the drill was recorded. Corrective Action: Develop a system to record and maintain records of evacuation drills moving forward. In the corrective action email include details of the system developed to ensure compliance with this rule moving forward.”

Correction date in the state record: Jan 10, 2025

Regulation 15.23: When a dishwasher is not available and single service items are not used; a three- compartment sink with adequate space for drain boards shall be required for the dishwashing, rinsing and sanitizing of dishes and utensils. Dishes shall be washed in hot, clean water at 120 degrees Fahrenheit (49 degrees Celsius), rinsed in hot, clean water and immersed for 2 minutes in sanitizing rinse. Bleach solution shall be used following the instruction of the manufacturer regarding sanitizing. Hand washed dishes shall be air-dried.

“Staff A stated the program hand washes dishes used by children. When asked to describe the process, Staff A stated soap and water is used, and that they were unaware of the 4-step process as stated by this rule. This rule was reviewed with the program on 5/27/2022 during a technical assistance visit. Corrective Action: If a dishwasher is not used, that the 4-step process is used to clean, and sanitize dishes/utensils used by children in the program.”

Correction date in the state record: Jan 11, 2023

Regulation 4.4: A system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the Afterschool Child Care Program, shall be established.

“Upon arrival twenty (20) children were in care; eighteen (18) were reflected on the sign in sheet. This was shared with Staff A who went through the list and determined the two (2) children present who were not accounted for. This rule was reviewed with the program during the 8/19/2022 technical assistance visit. Corrective Action: Ensure that attendance is taken upon the arrival and departure of each child. Develop a system to ensure checks are done to confirm accuracy.”

Correction date in the state record: Feb 1, 2023

Regulation 5.14: 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.

“Staff A and Staff D were the only two (2) staff present; neither have been cleared to be alone with children. This rule was reviewed with the program on 5/27/2022 and 8/19/2022 during technical assistance visits. Corrective Action: Ensure there is at least one (1) staff person on site who has been cleared to be alone with children. Ensure children are not left alone with anyone not cleared by the Child Development Division.”

Correction date in the state record: Feb 2, 2023

Regulation 5.11: The licensee shall ensure that any new individuals regularly present at the Afterschool Child Care Program submit a Records Check Authorization form to the Division prior to working with children in the Afterschool Child Care Program.

“Staff A stated that Volunteer B is present weekly on Tuesdays. Volunteer B has not submitted a record check to the Division. This rule was reviewed with the Division on 5/27/2022, 7/22/2022 and 8/19/2022 during technical assistance visits. Corrective Action: Prior to Volunteer B returning to the program, ensure a record check is submitted to the Division. Develop a system to ensure ongoing compliance to this rule is maintained.”

Correction date in the state record: Feb 2, 2023

Regulation 10.9: Emergency evacuations shall be practiced with the children each month. A record of practice drills for the previous and current year shall be maintained and available onsite. Practice drills may be pre-announced. There shall be: * a system in place to assure that all children are accounted for at a predetermined safe place; * a safety plan that may include additional lock down practices and procedures.

“Evacuation drills were not documented for October, November or December 2022, despite Staff A stating that the drill had been completed. This rule was reviewed with the program on 7/22/2022 and 8/19/2022 during technical assistance visits. Corrective Action: Ensure evacuation drills are documented monthly. Develop a system to ensure ongoing compliance.”

Correction date in the state record: Feb 1, 2023

Regulation 5.12: The licensee shall ensure that all new staff prior to working with children in the Afterschool Child Care Program; 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 C has been employed at the program since November 2022, and Staff D since 1/06/2023; the Division had not received a record check authorization form. Staff E has not completed fingerprinting; the fingerprint authorization form was generated on 10/07/2022. Corrective Action: Ensure a record check is submitted for Staff C and Staff D prior to the next time they are present, or by 2/01/2023, whichever comes first. Ensure Staff E submits to fingeprintinting by the due date. Develop a system to ensure record checks are submitted for all staff prior to working in the program, and that fingeprinting is completed in a timely manner.”

Correction date in the state record: Feb 2, 2023

Regulation 5.23: The licensee shall maintain a legally notarized affidavit onsite, signed by the licensee or designee, testifying that each staff file contains these records as required in the rule 5.22 of these regulations. The licensee shall permit representatives of the Division to have full access to off-site records to verify documentation.

“Upon review of the affidavit on site, it was found that fourteen (14) people were on the form, but not on the programs associated parties list, and four (4) staff on the associated parties list were not reflected on the affidavit. Corrective Action: If the program chooses to keep staff files off site, ensure that an up-to-date affidavit is on site as required by this rule.”

Correction date in the state record: Feb 1, 2023

Regulation 7.4: After a child has checked into the program, under no circumstances shall a child exit the program unless accompanied by a parent or authorized person with the exception of a child who has written parental permission to exit the program on his or her own at a specified time.

“Eleven (11) children left at 3:30 to go to a club activity unaffiliated with the program. When asked if the program had permission to release the children to the group activity, Staff A stated no. Corrective Action: Ensure children are only released to clubs, sports, or other individuals only when written permission is on file granting permission to do so.”

Correction date in the state record: Feb 1, 2023