Cathy Peno

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 provided stated that she completed monthly fire drills with the children but could not provide any documentation. Corrective Action: Immediately create a system where fire drills are documented monthly. By 9/10/25 submit to this Licensor the system you have developed to ensure monthly evacuation drills are documented.”

Correction date in the state record: Sep 10, 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.

“A review of the provider BFIS Quality and Credential Account, indicated that 11 of 15 professional development hours are documented during the review period from 12/05/23 to 12/05/24. The provider could not provide additional documentation. Corrective Action: By 9/10/25, submit a program improvement plan indicating how you will complete the remaining four (4) hours for 2023 to 2024 and the next 15 hours for the period of 12/05/2024 to 12/05/2025. This plan should include a time frame for completion of the past four (4) hours and the name of the training you will complete. In addition, indicate the time frame for the completion of the following 15 hours. Submit electronically the training certificates to Northern Lights at CCV with a cover sheet and provide a copy of the received email from Northern Lights to your licensor. Submit additional training certificates electronically to Northern Lights moving forward.”

Correction date in the state record: Sep 10, 2025

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.

“A review of attendance records relfect that no attendance has been recorded for the program since January 19, 2023. There were five (5) children in care upon arrival to the program and no children were signed in. This is a repeat violation which was cited on 09/20/2013, 03/19/2015, 07/21/2017, 12/19/2019 and 11/29/2023. Corrective Action: Immediately plan to document the time when each child arrives and departs the program each day. As this is a repeat violation, a program improvement plan has been assigned. In the program improvement plan, include details of: 1. the system you will initially implement to prompt you to record arrival and departure times for each child as they arrive and depart the program each day, 2. the visual reminders you will use to prompt yourself, 3. the auditory(alarm, buzzer, otherwise) prompt you will use, 4. where you will keep your attendance records to ensure they are visible and consistently accurate throughout your hours of operation each day moving forward.”

Correction date in the state record: Sep 27, 2024

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.

“While the provider stated that she does perform monthly evacuation drills, she was not able to provide a written record of any drills performed since the last compliance visit on 11/29/2023. Corrective Action: Immediately plan to conduct and record at least two evacuation drills per month for the months of September, October, November and December 2024, and then to conduct and record evacuation drills one time per month thereafter. In the corrective action email, provide details of a system you have established to prompt you to perform the evacuation drills as previously described.”

Correction date in the state record: Sep 27, 2024

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.

“A review of attendance records reflected that no child's attendance had been recorded since September 8, 2023. Cathy stated that children have been in attendance regularly since September 8, 2023. There were three children in care during this visit and no children were signed in. Corrective Action: Immediately plan to record attendance for every child who attends care in a manner which reflects the exact time each child arrives and departs each day they attend. As discussed, develop a system, such as keeping the attendance book on the counter and readily available, in an attempt to remind yourself to sign children in and out of care in a timely manner moving forward.”

Correction date in the state record: Feb 22, 2024

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.

“It was determined that the qualification documentation, first aid and CPR certification, and required professional development for Cathy's assistant were not available or up-to-date in her BFIS quality and credentialing account. Cathy's assistant has been in the program longer than 6 months. Documentation of Cathy's current first aid certification is not in her BFIS quality and credentialing account. It is required to have an up-to-date BFIS Quality and Credentialing Account. Corrective Action: Submit all annual professional development, verification of qualifications, and current first aid and CPR certificates to Northern Lights at CCV. Email confirmation to this licensor when required documents have been sent and a program improvement plan on how your BFIS Quality and Credential Account will be up-to-date and maintained.”

Correction date in the state record: Jan 3, 2020

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.

“Cathy shared that she hasn't documentated attendance since mid- November. This is a repeat violation previously cited on 7/21/2017, 3/19/2015, and 9/20/2013. Corrective Action: Effective immediately, ensure that attendance is being kept accurately with the time a child arrives and departs each day documented. Create a program improvement plan to ensure that the attendance is being maintained each day, send this plan to this licensor by 1/6/2020.”

Correction date in the state record: Jan 3, 2020

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.

“The last date the attendance was documented was 7/12/2017. Cathy stated she had not completed the attendance for the 7 days that were missing. This is a repeat violation previously cited on 3/19/2015 and on 09/20/2013. Corrective Action: Effective immediately, maintain daily attendance using a time in and time out system as required in this rule. By 08/4/2017, Cathy will send an email describing the system she will use to ensure compliance.”

Correction date in the state record: Aug 18, 2017