Gan Yeladim Preschool

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 violation was cited to this rule on 7/13/26 with corrective action required by 8/13/26. The program was contacted on 9/1/26 to obtain outstanding corrective action. An incomplete response was received. On 9/10/26 Northern Lights confirmed that all documentation required to be submitted based on the violation cited had not been received. Corrective Action: Ensure a comprehensive review of staff BFIS accounts are completed and for all staff employed six (6) months or longer have all education documents, required trainings and professional development certificatse submitted to Northern Lights at CCV by the stated due date. E-mail Supervisor Humphries by the due date to confirm all documentation has been submitted. A full audit of staff BFIS accounts will be conducted post due date. Failing to meet corrective action may result in further licensing action. Status: Appeal Period.”

Regulation 5.10.1.8: Childhood Lead Poisoning Prevention The licensee 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.

“A violation was cited to this rule on 7/13/26 with corrective action due 8/13/26. The original violation stated: Perform IRC (Inspection Repair and Cleaning) procedures and report via the Vermont Department of Health portal. Contact Licensing Supervisor [name] when this has been completed. Outreach post corrective action due date was done with Vermont Department of Health who confirmed this requirement has not been met. The program was notified of this on 9/1/26 and incomplete corrective action was received and further attempts to obtain full corrective action were not received. Corrective Action: Ensure the IRC is completed and filed electronically with Vermont Department of Health. Failure to meet corrective action may result in further licensing action. Status: Appeal Period.”

Correction date in the state record: Oct 3, 2026

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 violation was cited to this rule on 7/13/26 with corrective action due 8/13/26. The program was contacted on 9/1/26 to obtain overdue corrective action but was not confirmed to be complete nor submitted to Northern Lights at CCV. Corrective Action: Ensure all staff required to have completed this training do so by the due date and documentation is submitted to Northern Lights at CCV. Failure to complete corrective action may result in further licensing action. Status: Appeal Period.”

Regulation 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.

“Staff X found two (2) year old Child A standing in the parking lot approximately ten (10) feet from the entrance to the garden area where their classroom was. Staff estimate that Child A was in the parking lot between three (3) and five (5) minutes. The child was able to acces the parking lot because there is an open space between the garden area and parking lot. Staff X was in the garden area prior to noticing Child A, Staff X had walked towards the building. Staff Y and Z were located under the overhang near the building exit supervising water play. This is a serious violation. Corrective Action: Ensure that when staff are outside they are spreading out and actively supervising all areas of the palyground. The program will be required to install a fence and gate in that section. Each staff member will review this violation and work with the Director to identify areas where staff will position themselves to ensure all areas of the outdoor space. Email this licensor and confirm that the violation was reviewed and a plan is in place for outdoor supervision positioning. .A Parental Notification Letter (PNL), which is a copy of the licensing report, must be provided to each parent of every child enrolled within ten (10) days of the report submission. Please provide this licensor with the parent contact information for all children enrolled at the program. Status: Appeal Period.”

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.

“Five (5) out of fifteen (15) staff who have been employed for over six (6) months did not have up-to-date BFIS accounts as required. Corrective Action: Submit all identified missing documentation and notify Licensing Supervisor [name] when it has been submitted. Status: Appeal Period.”

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.

“One (1) staff member who has been employed for over six (6) months had not followed through with their out of state child abuse and neglect registry check paperwork. Corrective Action: The identified staff member completed the paperwork and submitted it to the Division after the visit. Submit a plan to Licensing Supervisor [name] that describes how the program will ensure that staff completes all portions of their background clearances to the Division within sixty (60) days of hire.”

Correction date in the state record: Sep 3, 2026

Regulation 5.10.1.8: Childhood Lead Poisoning Prevention The licensee 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.

“The IRC (Inspection Repair and Cleaning) reporting to the Vermont Department of Health is not current. This must be completed annually. Corrective Action: Perform IRC (Inspection Repair and Cleaning) procedures and report via the Vermont Department of Health portal. Contact Licensing Supervisor [name] when this has been completed. Status: Appeal Period.”

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.

“Staff A completed eleven (11) out of fifteen (15) hours of annual professional development between 6/13/2025 and 6/12/2026. Staff B did not complete any professional development between 7/2/2025 and 7/1/2026. Staff B is a college student, however none of their courses counted towards annual professional development in the period identified. Corrective Action: Staff A completed twenty-four (24) hours of professional development at a conference between 6/25/2026 and 6/26/2026 and therefore has made up the time missed over the previous year in addition to completing all required professional development for this year. For Staff B, please submit a plan to Licensing Supervisor [name] that describes how Staff B will complete the missing fifteen (15) hours of professional development as well as the fifteen (15) hours needed by 7/1/2027.”

Correction date in the state record: Sep 3, 2026

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 over a year as a Trainee does not have documentation of having completed the requirements of either a three (3) credit class in child or human development, Fundamentals for Early Childhood Professionals or the Vermont Afterschool Essentials Certificate. Corrective Action: Submit a plan to Licensing Supervisor [name] that describes how the identified staff will meet qualifications.”

Correction date in the state record: Sep 1, 2026

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.

“Three (3) staff who have been employed for over three (3) months do not have documentation of having completed First Aid/CPR training. Corrective Action: Ensure that all three (3) staff complete First Aid/CPR certification and submit their certificates to Northern Lights at CCV. Contact Licensing Supervisor [name] when the certificates have been submitted to Northern Lights at CCV. Status: Appeal Period.”

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.

“One (1) staff member who has been employed for over six (6) months does not have documentation of an approved orientation training or mandated reporter training. Corrective Action: Have the identified staff check their Penn State account and see if the Vermont Orientation training was completed. Have them check their back emails to see if the approved mandated reporter training certificate is present. If the documents are found, submit the documents to Northern Lights at CCV and notify Licensing Supervisor [name] when they have been submitted. If neither of these documents is available, the identified staff member must complete the training(s) and submit the certificates to Northern Lights at CCV and notify Supervisor Humphries when they have been submitted. Status: Appeal Period.”

Regulation 7.2.4: 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.

“The program has not received final record check clearance for Staff A or Staff B. Staff A was observed to be left alone with children twice during the visit, once for six (6) minutes and then for four (4) minutes. In addition, Staff A and B were observed to be left together in a classroom during nap time and no other person who has a cleared background check was present with them. Corrective Action: Immediately ensure that staff who have not received notification of final record check clearance from the Division are always working in tandem with someone who has received final clearance from the Division. By 11/17/2025, email Licensor [name] a list of which staff will be working in each classroom, and who will cover breaks in classrooms where there is a staff member who has not received final clearance from the Division so that they will not be alone with the children. Confirm that Staff A and Staff B have both completed everything needed for their background clearances, including fingerprints and out of state child abuse and neglect registry check paperwork. Confirm that all staff know who can and cannot be left alone with children.”

Correction date in the state record: Nov 13, 2025

Regulation 3.7.2.2: The licensee shall ensure that evacuation drills are conducted at least once a month, and children and staff are evacuated in under three (3) minutes. Licensees of a CBCCPP located within a public or independent school building may count a lock-down drill performed while the CBCCPP is in operation in place of a monthly evacuation drill with the CBCCPP children and staff and at least three (3) of the monthly drills conducted within 365 days shall be evacuation drills.

“Between September 2024 and the date of the visit, the program was missing five (5) monthly evacuation drills. Corrective Action: For the months of August 2025 through December 2025, conduct two (2) evacuation drills per month. Record all evacuation drills and submit the evacuation drill logs to Licensor [name] on by the first of the month, every month until January 1, 2026.”

Correction date in the state record: Dec 23, 2025

Regulation 3.4.6.5: Staffing Schedule: A licensee shall maintain a written record of the daily schedule for at least 365 days of all staff including exact days and hours worked and the group of children to whom they are assigned.

“As a result of a concern brought to the Division, the following information was discovered. All staff interviewed, including the director, stated that staff are not required to sign in or out of classrooms throughout the day. The director confirmed that the core classroom staff do not sign into or out of the program because they are on salary. This does not meet the requirements to have record of the exact hours worked and which group of children staff are assigned to at any given time. Corrective Action: Immediately ensure that staff are signing in and out of the classrooms or groups of children each time they enter and leave the groups, including for break coverage and extended care. This can be done through the Brightwheel app that is already in use or on paper. Email Licensor [name] confirmation of understanding this rule and a plan that describes what method staff will use to sign in and out of classrooms each time they enter or exit and how the staff will be trained to sign in and out of each room where they work.”

Correction date in the state record: Sep 11, 2025

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.

“The climbing wall structures are used with supervision by children age three (3) years and up do not have any cushioning material in the use zones. The cushioning material in the use zone for the climber/slide/swing appears to be running low, but was unable to be measured. Corrective Action: Confirm that the climbing walls have been made inaccessible to children until sufficient cushioning material has been installed. For the climber/slide/swing unit, dig down and measure cushioning material to ensure that the material meets the depth for the type of material and the height of the equipment as recommended by the U.S. Consumer Product Safety Commission Public Playground Safety Handbook. The handbook can be found at: https://www.cpsc.gov/s3fs-public/325.pdf. If it does not meet the required depth, do not allow children to use the equipment until sufficient cushioning material has been added to meet the required depth.”

Correction date in the state record: Sep 11, 2025

Regulation 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.

“As a result of a concern brought to the Division, the following incident was reported and substantiated. Staff reported that Staff E was left alone with a group of twelve preschool children for at least one (1) hour while Staff A was off the premises. The majority of interviewed staff stated that Staff A often leaves the preschool classroom prior to their schedule break and/or prior to the end of their schedule shift, leaving Staff B alone with eleven (11) to thirteen (13) preschool children. Staff report that at least two (2) times a week, multiple classrooms are left over ratio when the staff who open the program leave at 2:30 PM and the afternoon coverage does not arrive until 3:00 PM. The program director said she was aware of a few times when classrooms have operated out of ratio. Staff report that they have been advised by the program director that they were able to leave their group of children regardless of ratio, as long as other staff were nearby. Nearby was described as in the upper playground or in the classroom across the hall. Staff reported that there is not consistent communication when staff leave classrooms over ratio and that other staff are not aware when a group is over ratio or when staff need to provide supervision for children outside their group. The upper and lower playgrounds do not allow for visual supervision of staff or children. This is a serious violation. Corrective Action: Immediately ensure that ratios and group size are maintained in all classrooms at all times. This may mean closing classrooms if staffing does not allow for ratios and group size to be met. Since this is a serious violation that impacts the safety of the children, a program improvement plan is assigned. In the program improvement plan, include: 1. How the staff will be trained so that they understand child/staff ratios and group size; 2. A system for staff to reach out for assistance immediately in the event of being over ratio; 3. A plan to respond immediately to the issue; 4. A policy for expectations of staff to ensure staff stays with the children after 2:30 until there are adequate staff to ensure age appropriate ratio is maintained; 5. A system to handle times when staff are out unexpectedly and there are no other staff available for some or all of the day; 6. How staff schedules will be adjusted as needed to account for proper ratios at all times. In addition, since this is a serious violation, a hard copy or digital version of this report must be sent to all families of enrolled children by 8/25/2025. Email Licensor [name] a list of all enrolled children, including the names and contact phone numbers of their parents or legal guardians.”

Correction date in the state record: Sep 12, 2025

Regulation 3.2.5: Self-reported violations: If an incident or situation occurs in a CBCCPP while children are present that could be considered a serious violation as defined in the rule 2.2.50 of these regulations, the licensee has a responsibility to self-report this to the Division within twenty-four (24) hours of the incident. A complete report will include a description of the incident, what the licensee has done to verify the particulars of what occurred, and how the licensee has taken corrective action to ensure the safety and well-being of children and to prevent a future serious violation. If such a report is received in a timely manner from a licensee with a history of consistent regulatory compliance, no child has been seriously injured or harmed as a result of the incident or situation, and the licensee has taken prompt and appropriate corrective action; the Division may, on a case by case basis and at the Division's discretion, elect to issue a warning, rather than a violation related to that incident or situation.

“As a result of a concern brought to the Division, the following incident was reported and substantiated. Staff and director testimony indicates that the director was aware that Child X was missing and unsupervised for at least five (5) and as much as fifteen (15) minutes and did not make a report to the Division. The director said that she knew to report incidents where children are injured at the program and receive medical care by a physician, but was not aware of other incidents that must be reported to the Division. Corrective Action: Email a statement to Licensor [name] that confirms your understanding of this rule.”

Correction date in the state record: Sep 11, 2025

Regulation 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.

“As a result of a concern brought to the Division, the following incidents were reported. Through staff interviews it was determined that on 7/1/2025 Child X left the preschool group without the knowledge of Staff A and B who were assigned to the preschool group Child X was in. Child X left the classroom without Staff B's knowledge while Staff A took a group of three (3) children outside. Child X attempted to go outside when Staff C, assigned to another group, was transitioning outside. Staff C notified Staff A upon getting outside of Child X's whereabouts. Staff A went inside to address this and did not locate Child X, and Staff B was uncertain where Child X was when asked. The Director and Staff A began searching for Child X and ultimately located Child X with their father who had not signed Child X out of the classroom, in a space that required Child X to go through several doors of the building leading to non-childcare space. Child X was upset and crying when found, and it is estimated that they had been unaccounted for by the program for at least fifteen (15) minutes. Additional incidents of staff supervision concerns were discovered through staff interviews. The first occurred over a month ago; Staff A had dropped off the remaining preschool children with Staff G for the aftercare program. Staff A gathered their personal belongings and headed outside to discover preschool Child Y in the parking area by themselves. It is unknown how long Child Y was unattended. The second reported incident found that a few weeks ago preschool Child Z, was found outside the downstairs door at the new building and was crying. The preschool group had transitioned inside to their classroom a few minutes earlier. A staff member discovered and returned Child Z to the preschool room. The director stated that Child Z was supervised but walked away from their group outside and was brought inside by another group. Two interviewed staff stated that at least twice per week, preschool children are found outside of the preschool classroom without the knowledge of Staff A and Staff B. Other staff members have returned these children to the preschool classroom each time. This is a serious violation. Corrective Action: Effective immediately ensure that staff maintain active supervision of all children at all times. The parents of Child Y and Z must be notified of the incidents; it is assumed that the parents of Child X are aware since Child X was found with their father. Due to the seriousness of this violation, a program improvement plan is required, which should include: 1. Policies for keeping fire doors, classroom doors, and stairwell doors closed; 2. A training plan for Staff A and B that is specific to active supervision of young children; 3. A policy for cell phone use; 4. Details on training staff for door security and cell phone use. Additionally, the program director must collaborate with SPARQS for coaching on managing difficult conversations with staff and staff accountability. In addition, since this is a serious violation, a copy of this report, either hard or digital must be sent to all enrolled families by 8/25/2025. Also, please email Licensor [name] a list of all enrolled children, with their parents' or guardians' contact details.”

Correction date in the state record: Sep 12, 2025

Regulation 7.2.4: 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.

“As a result of a concern brought to the Division, the following incident was reported and substantiated. Staff A left the preschool group alone with a new substitute, Staff E who had not received a final clearance letter from the Division based on a fingerprint supported background check. Staff statements reflect that Staff E was alone with the preschool group for approximately one hour, while Staff A was off school premises. In addition, during the compliance visit which occurred on this same day, it was found that Staff E and Staff F were working together with a group of children and neither staff has received final clearance from the Division. In addition, during the compliance visit, there were three (3) infants found in the building outside of the licensed space with one (1) adult who was providing care. The adult providing care was not present on the Associated Parties list for the program, nor were they found anywhere in BFIS. This means that they have not completed a fingerprint supported background clearance for the Division. Corrective Action: During the visit, the director separated staff E and F and ensured that each was working alongside a staff member who had received the necessary clearance. Since the visit, the director notified Licensor [name] that the infants are no longer being cared for in the building. Moving forward, please always ensure that any staff members who have not received their final background clearance are paired with a cleared staff member who can always see and hear them. Email a plan to Licensor [name] that outlines your understanding of this requirement and the strategies the program will implement to ensure compliance, including how break times and transitions will be managed.”

Correction date in the state record: Sep 11, 2025

Regulation 5.6.5: All prescription medication administered by staff shall be in its original container, properly labeled for the child, and administered prior to the expiration date on the container.

“There was one (1) epi-pen at the program. It was labeled and the plan was in place, but the original box with the prescription was not present. Corrective Action: By 9/27/2024, email Licensor [name] to confirm that the original prescription box for the epi-pen is stored with the epi-pen. Moving forward, ensure that all medications are in their original packaging, and that prescription medications include the prescription labeling.”

Correction date in the state record: Mar 28, 2025

Regulation 2.3.9.3: The licensee shall ensure that all staff have met ongoing background check requirements by submitting at least once every five (5) years a Records Check Authorization form to the Division and as required shall submit to fingerprinting.

“One (1) staff member was due for five-year fingerprint renewal and had not started the process as of the visit date. Corrective Action: The staff member sent their Record Check Authorization Certificate to the Division after the visit. By 10/4/2024, email Licensor [name] confirmation that the identified staff member followed through with fingerprinting.”

Correction date in the state record: Dec 10, 2024

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.

“The program was unable to provide documentation that three (3) out of twelve (12) staff who have been employed for over three (3) months have current First Aid/CPR Certification. Corrective Action: By 10/4/2024, ensure that the three (3) staff missing current First Aid/CPR certification receive their certification and email the certificates to Northern Lights at CCV. Copy Licensor [name] on the submissions. Additionally, by 10/4/2024, email a plan to Licensor [name] that describes how the program will ensure that all staff obtain First Aid/CPR certification within the first three (3) months of employment and maintain certification before or on their certification expiration dates.”

Correction date in the state record: Jun 24, 2025

Regulation 3.7.3: Emergency Preparedness Training: Within 365 days of opening a CBCCPP, the licensee shall attend emergency preparedness training which shall include content specifically related to sheltering in place in the event of an emergency in which the licensee and children present need to remain in the CBCCPP for an extended period.

“The director was unable to provide proof of having completed an emergency preparedness training. Corrective Action: By 10/4/2024, email the certificate that shows that the director has completed an emergency preparedness training to Licensor [name].”

Correction date in the state record: Dec 9, 2024

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.

“At the time of this visit, there were four (4) people present that were not on the program's employment list. The program director said that the forms had been faxed to the Division, and did not remember when they were faxed, and did not provide the original record check authorization forms that had been faxed. There were two (2) substitutes who have not followed through with all components of their background clearances. Corrective Action: The program sent record check authorization forms for three (3) staff the day after the visit. Two (2) were signed and dated 8/29/2024 and one (1) was signed and dated 9/29/2024, which appears to be a mistake. One (1) staff person submitted their out of state child abuse and neglect form to the Division. By 10/4/2024, ensure that all staff have sent record check authorization forms to the Division and follow through with fingerprinting and out of state child abuse and neglect registry checks as identified. Also by 10/4/2024 send confirmation to Licensor [name] that all staff present have submitted the necessary documents to the Division and, as indicated, have complied with fingerprinting. Additionally, by 10/4/2024, email a plan to Licensor [name] that describes how the program will ensure that record check authoriazation forms will be submitted to the Division for all staff on or before their first day of work at the program.”

Correction date in the state record: Jun 24, 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.

“Thirteen (13) out of fourteen (14) 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: By 10/4/2024, send all identified outstanding qualification documents and training certificates to Northern Lights at CCV. Copy Licensor [name] on the submissions.”

Correction date in the state record: Jun 24, 2025

Regulation 5.10.6.1.1: The licensee shall ensure that any vehicle, owned by the CBCCPP, used for transporting children be registered, inspected, and insured according to state law.

“The program did not provide documentation that the school's vehicle used to transport children is registered, inspected, and insured according to state law. Corrective Action: By 9/27/2024, email proof of insurance, registration, and inspection to Licensor [name] for the school's vehicle.”

Correction date in the state record: Mar 28, 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.

“At the time of the visit, five (5) staff who have been employed at the program for longer than sixty (60) days have not followed up with all steps involved in their required background clearances. Four (4) of the staff have been employed for at least four (4) months. Corrective Action: The program director reported that some of the staff have followed through with setting up fingerprinting appointments and has sent required paperwork for out of state child abuse and neglect registry clearances to the Division since the visit. By 1/8/2024 confirm that all staff have completed all steps regarding background clearances, to include attending fingerprint appointments and sending required out of state paperwork to the Division. Also, by 1/8/2024, email a plan to Licensor [name] that describes how the program will ensure that the staff follows through with all steps attached to background clearances in a timely manner.”

Correction date in the state record: Aug 28, 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.

“Five (5) staff who are in positions to be counted in staff/child ratio or have been employed with the program for longer than thirty (30) days have not completed an approved orientation training. Corrective Action: By 1/8/2024 ensure that all five (5) staff have completed an approved orientation training and submitted it to Northern Lights at CCV. Copy Licensor [name] on the email submission. Also, by 1/8/2024, email a plan to Licensor [name] that describes how the program will ensure that staff completes an approved orientation training before counting in staff/child ratio, or within thirty (30) days of hire if they are not in positions to be left alone with children or count in ratio.”

Correction date in the state record: Jan 11, 2024

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.

“Six (6) staff who are in positions to be counted in staff/child ratios have either not completed pediatric first aid and infant and child CPR within three (3) months of beginning work in the program or have not remained currently certified. Corrective Action: Prior to the release of this report, the director sent the First Aid/CPR certificate for one (1) staff member. By 1/12/2024 ensure that all additional staff who have been employed for three (3) months or more have completed pediatric first aid and infant and child CPR certification and send the certificates to Northern Lights at CCV. Copy Licensor [name] in the submission. Also, by 1/12/2024 email a plan to Licensor [name] that describes the method the program will use to ensure that all staff is certified in pediatric first aid and infant and child CPR within three (3) months of hire, and how the program will monitor when staff is due for renewal and ensure staff follow-through.”

Correction date in the state record: Jan 11, 2024

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

“Four (4) staff have not completed the approved mandated reporter training. Corrective Action: By 1/8/2024 ensure that all four (4) staff have completed the approved mandated reporter training and submitted it to Northern Lights at CCV. Copy Licensor [name] on the email submission. Also, by 1/8/2024, email a plan to Licensor [name] that describes how the program will ensure that all staff and auxiliary staff completes the approved mandated reporter training before working with children.”

Correction date in the state record: Jan 18, 2024

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.

“Three (3) out of six (6) classrooms are not led by a staff member who at least qualifies as a Teacher Associate for 75% of the time children are present. Corrective Action: By 1/8/2024, email a plan to Licensor [name] that describes ow the program will staff each classroom with at least one (1) person who is qualified as a Teacher Associate or higher for 75% of the time that children are present at the program.”

Correction date in the state record: Feb 6, 2024

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.

“The playground has a climber/slide/swing structure on one side of the playground and a climbing wall on the other side of the playground that have no cushioning material installed in the use zones. The children physically have access to the areas that allow them to reach thirty (30) inches or higher off the ground. Corrective Action: Program staff stated that the children are not allowed to use the areas of the climbers that allow them to reach thirty (30) inches or higher off the ground. There is a plan already in place for contractors to install cushioning material during the week of 7/24/2023. Effective immediately, make all structures that allow children to attain a height of thirty (30) inches or more inaccessible to the children and send confirmation via email to Licensor [name]. By 8/3/2023, email confirmation to Licensor [name] that the cushioning has been installed.”

Correction date in the state record: Jul 26, 2023

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.

“An audit of ten (10) children's files shows that nine (9) out of ten (10) files did not include documentation of the children's age-appropriate well care exam. Corrective Action: By 1/20/2023, submit a program improvement plan to Licensor [name] that describes how the program will ensure that well care exam documentation is collected for existing enrolled children and added to their files. In the plan, include how the program will ensure that this documentation is collected for newly enrolled children within forty-five (45) days of enrollment.”

Correction date in the state record: Jan 20, 2023

Regulation 7.2.4: 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.

“At the time of this visit, there were four (4) staff members who have been employed for more that sixty (60) days who had not completed the entire fingerprint supported background clearance. Staff members A and B have been employed for almost eighteen (18) months. Corrective Action: Staff A emailed a receipt to Licensor [name] to show that they were fingerprinted on 12/29/2022. By 1/6/2023, Staff A shall send their completed out of state child abuse and neglect forms for each state they have lived in the past five (5) years to the Division and Staff B shall email their receipt that shows they were fingerprinted. By 1/13/2023 the remaining staff members shall email receipts that they have been fingerprinted and/or submit completed out of state child abuse and neglect forms for each state they have lived in the past five (5) years to the Division. By 1/20/2023 the program shall submit a program improvement plan to Licensor [name] that describes how the program will assure that fingerprint supported background clearances will be completed within sixty (60) days of each staff's employment.”

Correction date in the state record: Jan 20, 2023

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.

“An audit of BFIS quality and credential accounts and documents provided by the program shows that at the time of the visit, nine (9) out of sixteen (16) staff or auxiliary staff, all of whom have been employed for more than thirty (30) days did not complete an approved orientation training. In addition, six (6) out of sixteen (16) staff or auxiliary staff, all of whom have been employed for more than thirty (30) days have not completed an approved mandated reporter training. Corrective Action: One (1) staff member completed an orientation training the day of the visit. By 1/20/2023, the remaining eight (8) staff shall complete an approved orientation training and the program shall email the certificates to Licensor [name]. By 1/20/2023, the six (6) staff who have not completed mandated reporting training shall complete that training and the program shall email the certificates to Licensor [name]. In addition, by 1/20/2023, submit a program improvement plan to Licensor [name] that describes how the program will assure that staff complete an approved orientation before they are left alone with children, or if they are not left alone with children, within a month of their first day of working with children.”

Correction date in the state record: Jan 20, 2023

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.

“An audit of BFIS quality and credential accounts and documents provided by the program shows that at the time of the visit, four (4) out of five (5) staff who hold positions that require annual professional development and have been employed for a year or more have not completed the required fifteen (15) hours of annual professional development. Corrective Action: By 1/20/2023, submit a program improvement plan to Licensor [name] that describes how staff who hold positions that require annual professional development will complete fifteen (15) hours of professional development for the 2021 - 2022 year in addition to completing fifteen (15) hours of professional development for the 2022 - 2023 year. In the plan, also describe how the program will assure that all staff in positions that require professional development complete all fifteen (15) hours of annual professional development.”

Correction date in the state record: Jan 20, 2023

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 documents provided by the program shows that at the time of the visit, eight (8) out of fifteen (15) staff who are either left alone or count in staff/child ratios and have been employed for more than three (3) months do not hold current certification in pediatric first aid and in infant and child CPR. This is a repeat violation. Corrective Action: By 1/20/2023, the program will submit a program improvement plan to Licensor [name] that describes how the program will assure that all current staff who are left alone with children and/or are counted in staff/child ratios complete certification in pediatric first aid and in infant and child CPR, how the program will assure new staff complete their certification within three (3) months of start date, and how the program will assure staff maintain First Aid/CPR certification.”

Correction date in the state record: Jan 20, 2023

Regulation 3.4.6.1: The licensee shall maintain a record of the date of each evacuation drill as required in the rules in section 3.7.2 of these regulations that includes the number of children and 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. When the CBCCPP counts lock-down drills as allowed in the rules in section 3.7.2 of these regulations, the licensee shall maintain a record of the date of each lock-down drill, the number of CBCCPP children and staff who participated, and note that the drill performed was a lock-down drill.

“On 10/20/2022, Staff A said that the program has been practicing evacuation drills because the fire alarms in the building were triggered for various reasons several times since last winter. They said that the Burlington Fire Department fined the organization due to the number of false alarms. This licensor sent an email to Staff B on 10/24/2022 asking for a copy of the fine that was issued by the Burlington Fire Department. Staff B sent information from the fire alarm company on 11/2/2022 that said that the only information they could give is that they were on site for service calls on 5/18/2022, 5/31/2022, and 8/19/2022 for accidental alarm activations and 9/1/2022 as a test. Staff B said that they were hired at the program the end of August, and to contact Staff A. Emails were sent to Staff A on 11/14/2022 and 11/28/2022 asking them to send a copy of the fine from the Burlington Fire Department. The copy of the fine was not sent. The program did not provide documentation of monthly evacuation drills for January, February, March, April, June, and July 2022. Corrective Action: Immediately begin conducting monthly evacuation drills and document the following information for each evacuation drill: the date of the evacuation drill, the number of children and staff evacuated, time taken to evacuate, and notation of the drill conducted while children are sleeping or resting. By 12/15/2022, submit a plan that describes the system that will be used to document evacuation drills.”

Correction date in the state record: Dec 19, 2022