Freedom Rains

Regulation 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.

“Staff members B, C, D, and E did not renew their First Aid/CPR certification by the date it was due. Staff F did not complete First Aid/CPR certification within three (3) months of their start date. Corrective Action: Ensure that Staff F completes First Aid/CPR certification. Send all certificates to Northern Lights at CCV. Notify Licensor [name] when they have all been sent. Additionally, send Licensor [name] a plan that describes how the program will track staff's First Aid/CPR certification and ensure that all staff complete First Aid/CPR within three (3) months of hire and how the program will ensure that renewal certification occurs on or prior to each staff's expiration date.”

Correction date in the state record: May 7, 2026

Regulation 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.

“Staff A administered medication to a child several times and does not have documentation of having medication administration training. Staff A thought it had been completed years ago and was unable to obtain documentation of it having been completed. Corrective Action: Ensure that no staff administers any medication unless they have documentation of an approved medication administration training. Send Licensor [name] a plan that describes how the program will keep track of who on staff has medication administration training. Additionally include in the plan how the program will ensure that there is always someone available to give rescue medications if there is not at least one (1) staff member in each classroom at all times who has the medication administration training.”

Correction date in the state record: May 7, 2026

Regulation 5.1.2: General Health Examinations: Within forty-five (45) days of enrollment, the licensee 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.

“Four (4) out of ten (10) children's files audited were missing documentation of their general health exams. Corrective Action: Review all children's files. Collect all missing documentation of age appropriate general health exams by 4/30/2025. Email Licensor [name] to confirm documentation of general health exams has been collected for all children who are missing this documentation.”

Correction date in the state record: May 7, 2025

Regulation 5.6.4: Written permission from parents to administer medication must include all of the following information for each prescription and non-prescription medication administered to children: * Name of the child; * Child's date of birth; * Any medication allergies; * Name of medication; * Dosage to be given; * Time when medication is to be given; * Route of administration (mouth, ear, nose, topical, inhalation); * Reason for the medication; * Start and end dates for administration of the medication; and * Any special instructions.

“There were at least five (5) medications without parental permission to administer. Corrective Action: The program stated that they sent medication permission forms home to all families of children with ongoing medications. Please email a blank permission form that the program will be using for medications to Licensor [name]. By 4/30/2025, email Licensor [name] and confirm that all medications have corresponding permission forms signed by parents/guardians.”

Correction date in the state record: May 7, 2025

Regulation 6.2.4.3: The program director shall ensure that each group of children is led by a staff member who is at least qualified as a teacher associate for at least 75% of the hours of operation.

“Two (2) groups of children are led by staff who are not qualified as a Teacher Associate or higher. Corrective Action: Staff A has six (6) qualifying credits and is working toward their Child Care Certificate. Staff B has completed Fundamentals training. Email Licensor [name] a plan that describes when Staff A will complete at least six (6) more credits to qualify for the expedited variance for staff qualifications. In the plan, describe who is going to mentor Staff A, what topics will be covered, and how the mentor will document mentoring sessions and goals achieved. Email Licensor [name] a plan that describes how the program will ensure that there is a qualified lead for the group of children that Staff B is in charge of. In the plan also include how Staff B will be supervised until a qualified lead can be found”

Correction date in the state record: May 7, 2025

Regulation 6.2.1.4: Staff who are qualified as defined in the rules in section 7.3 of these regulations, meet professional development requirements as defined in the rules in section 7.4 of these regulations, and are physically present and working with children may be counted in staff/child ratios.

“One (1) staff member who has been employed for a year has not yet completed Fundamentals training or a three-credit college course in child/human development as required. Corrective Action: By 4/30/2025, email Licensor [name] and confirm that the identified staff member has registered for Fundamentals training or a three-credit course that covers child/human development.”

Correction date in the state record: May 7, 2025

Regulation 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.

“Four (4) staff did not complete all components of their fingerprint supported background clearances within sixty (60) days of hire. Corrective Action: Ensure that all identified staff comply with fingerprinting and/or out of state child abuse registry checks as required. By 4/30/2025, email Licensor [name] receipts from fingerprint appointments for all identified staff. For those with out of state child abuse and neglect registry checks, confirm with Licensor [name] once they necessary paperwork has been sent to the Division. Until the program receives notification that the staff without completed background clearances are cleared, do not allow them to be left alone with children.”

Correction date in the state record: Aug 14, 2025

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

“Eight (8) staff do not have documentation of the approved mandated reporter training. Corrective Action: By 4/30/2025, ensure that the identified staff have completed the approved mandated reporter training and send the certificates to Northern Lights at CCV. Copy Licensor [name] on the submission.”

Correction date in the state record: May 7, 2025

Regulation 7.4.4: All staff shall complete fifteen (15) clock hours of annual professional development activities as required in the rule 7.4.2 of these regulations. Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt.

“Ten (10) staff who have been employed for over a year did not show documentation of having completed all fifteen (15) hours of annual professional development in their last full year. Corrective Action: By 4/30/2025 email Licensor [name] a plan that shows how each of the identified staff will complete the missing hours in addition to the fifteen (15) hours required for the current year by their next anniversary.”

Correction date in the state record: May 7, 2025

Regulation 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.

“Eleven (11) out of eighteen (18) staff who have been employed for over six (6) months do not have up to date BFIS quality and credential accounts as required. Corrective Action: Send all mandatory training documents, qualification documents and annual professional development certificates that are missing from BFIS to Northern Lights at CCV. Copy Licensor [name] in the submissions. Email Licensor [name] a plan that describes how the program will ensure that staff's quality and credential accounts are up to date by their six-month anniversary and maintained moving forward.”

Correction date in the state record: Jun 20, 2025

Regulation 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.

“Six (6) staff are missing documentation of an approved orientation training. Corrective Action: By 4/30/2025, ensure that the identified staff complete orientation training and send their certificates to Northern Lights at CCV. Also by 4/30/2025, copy Licensor [name] on the submission to Northern Lights at CCV.”

Correction date in the state record: May 7, 2025

Regulation 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.

“Seven (7) staff do not have documentation of having current First Aid/CPR certification. One (1) staff has current First Aid/CPR certification for adults only. Corrective Action: The program stated that they scheduled a First Aid/CPR certification course for Saturday, 4/4/2025 for those who are not yet certified. By 4/30/2025, email all identified First Aid/CPR certification cards to Northern Lights at CCV and copy Licensor [name] on the submissions.”

Correction date in the state record: Jun 24, 2025

Regulation 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.

“An audit of BFIS quality and credential accounts and staff files showed that twelve (12) staff who have been employed by the program for more than three (3) months, and are working with children, have either not completed pediatric first aid and infant and child CPR certification or have not renewed certification as required. Corrective Action: By 8/11/2023 email a plan to Licensor [name] that shows when staff will complete certification or recertification.”

Correction date in the state record: Aug 10, 2023

Regulation 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.

“On the Infant/Toddler playground, there was a large tire standing up, partially sunk in the ground that was over 30 inches high, with no cushioning material. On the Two-Year-Old playground, the ground was visible around the climbing structure, indicating insufficient depth of cushioning material. On the Preschool/Pre-K playground, the ground was visible around the climber and swings, indicating insufficient depth of cushioning material. Children were using the climbing structures/swings. Corrective Action: The areas indicated must immediately be made inaccessible for climbing and swinging until sufficient depth of cushioning material, according to the U.S. Consumer Product Safety Commission's Public Playground Safety Handbook (available at https://www.cpsc.gov/safety-education/safety-guides/playgrounds/public-playground-safety-handbook) has been installed. By 5/4/2023, submit a plan that describes when the cushioning material will be installed.”

Correction date in the state record: May 3, 2023

Regulation 5.10.4.5.1: The program director shall ensure that the CBCCPP, its furnishings, and toys are kept in a clean and orderly condition.

“In one the pre-kindergarten rooms: there is food debris around the microwave and dried urine and dirt around the base of the toilet. In the large preschool room: there is paint peeled off the wall in the bathroom, exposing the wallboard, and a wooden shelf in the classroom that is not sealed, both of which make the surfaces porous and not cleanable. In the two-year-old room: a shelf in the bathroom is damaged, and particle board in the shelf was exposed, causing it to be porous and unable to be cleaned, and cobwebs are trailing down off the ceiling. In the large preschool room, the pre-kindergarten room, and the two-year-old rooms there is visible dirt buildup on the lower parts of the walls, doors, and door jams. Corrective Action: Submit a plan for maintaining cleanliness in the described areas and to identify how the porous surfaces will be made non-porous.”

Correction date in the state record: May 31, 2022

Regulation 5.10.1.10.4: Materials required for routine cleaning shall be stored and used in a safe manner out of the reach of children.

“In the one-year-old room, the child safety lock on one of the cupboards under the sink is broken, and Lysol aerosol spray and other cleaners in that cupboard are accessible to children. In the two-year-old room, there is sunscreen and diaper cream with labels that read "keep out of reach of children" in drawers that children can access. In the large preschool room, there is sunscreen and insect repellant in children's cubbies, within reach of children. Corrective Action: Immediately make all cleaning/disinfecting products and all personal care products inaccessible to children. Submit a plan by 6/2/2022 describing how these products will be stored so that they are inaccessible to children.”

Correction date in the state record: May 31, 2022

Regulation 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 Quality and Credentialing accounts and documentation provided by the program shows that twelve (12) staff who have been employed longer than six (6) months do not have up-to-date BFIS Quality and Credentialing accounts. Staff A is missing documentation of CPR/First Aid certification and documentation for 6.5 hours of annual professional development. Staff B is missing documentation of qualifications, CPR/First Aid certification and mandated reporting. Staff C is missing qualification documentation. Staff D is missing documentation of Mandated Reporting. Staff E is missing documentation of Mandated Reporting. Staff F is missing documentation of CPR/First Aid certification. Staff G is missing documentation of CPR/First Aid certification. Staff H is missing documentation of CPR/First Aid certification. Staff I is missing documentation of CPR/First Aid certification and Mandated Reporting. Staff J is missing documentation of CPR/First Aid certification and Orientation. Staff K is missing documentation of Mandated Reporting. Staff L is missing documentation of qualifications, CPR/First Aid certification and Mandated Reporting. Corrective Action: The program sent documentation to Northern Lights at CCV for many staff on 5/18/2022. Send the remainder of the documentation to Northern Lights at CCV. Submit a plan describing how documentation of required trainings, qualifications, and professional development will be sent to Northern Lights at CCV in a timely manner moving forward.”

Correction date in the state record: May 31, 2022

Regulation 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.

“A review of BFIS Quality and Credentialing accounts and documentation provided by the program shows that four (4) staff who are in positions to be left alone with children did not complete an orientation training approved by the Division as required. Corrective Action: The program submitted training certificates for the four (4) staff that showed that the four (4) staff completed an orientation training after this regulatory compliance visit. Submit a plan that describes how the program will assure that the staff complete an orientation training approved by the Division in a timely manner moving forward.”

Correction date in the state record: May 31, 2022

Regulation 7.6.2: When there is a personnel change designating a new/different business manager, the licensee shall notify the Division prior to the change. The Division shall determine whether the new/different business manager meets qualifications as required in the rule 7.6.1 of these regulations, approve a time limited variance, or approve the program director as required in the rules in section 7.3.1 of these regulations.

“A review of staff BFIS Quality and Credential Accounts prior to the visit and review of documentation received from the program, there was no documentation to verify qualifications for the business manager. Corrective Action: By 5/14/21, submit a copy of the business manager's college transcripts or college diploma to Northern Lights to verify they meet qualifications to be the program's business manager.”

Correction date in the state record: May 18, 2021

Regulation 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.

“After a review of staff BFIS Quality and Credential Accounts prior to the visit and documentation received from the program, two staff had not obtain first aid and CPR trainings within the first three months of employment and three staff had renewed first aid and CPR after their certificates had expired. Corrective Action: By 5/14/2021, submit an improvement plan on how the program will ensure new staff obtain the required first aid and CPR trainings within three months of hire and all staff remain current with their certifications.”

Correction date in the state record: May 18, 2021

Regulation 7.7.2: The program director shall ensure that all volunteers are not counted in the staff/child ratios and are never left alone with any child or children in the CBCCPP; with the exception of a parent may be left alone with his/her own child(ren).

“Three individuals under 18 years of age were identified by the program as "volunteers". These individuals also reported that they were volunteers. Program records and staff statements support that these individuals were counted in Staff Child ratio which is prohibited by rule. It was later determined that these indivdiduals were not volunteering their time and were working directly with children. None of these individuals met minimum qualifications of any position. Corrective Action: The program immediately discontinued this practice. By October 15th, send your written understanding that all individuals counting in staff child ratio must meet minimum qualifications.”

Correction date in the state record: Oct 14, 2019

Regulation 7.2.1: The licensee shall ensure that any new individuals regularly present at the CBCCPP submit a Records Check Authorization form to the Division prior to working with children in the CBCCPP.

“It was identified that the program has had at least nine different individuals working with children that had not submitted a Record Check Authorization Form to the Division, during a period of time from May 2019 through July 2019. Staff statements and program records support this information. Corrective Action: By October 15th, send a program improvement plan that details the new procedure that will ensure that a Record Check Authorization Form has been submitted to the Division prior to those individuals working with children.”

Correction date in the state record: Oct 14, 2019

Regulation 6.2.1.7: Partner staff shall not be left alone with children and shall not count in staff/child ratios at the CBCCPP.

“On 4/2/2019, an individual identified as a Partner Staff and working for another agency, was left alone with nine children who were all reported to be two years of age. After five minutes, the Licensor requested that a staff member join the Partner Staff to provide minimal supervision. Corrective Action: By 5/20/2019 email this licensor a program improvement plan on how staff will be trained on the purpose of Partner Staff and their roles and limitations in the program as well as supervision of children and staff:child ratios when Partner Staff are present.”

Correction date in the state record: May 20, 2019