Good Shepherd's Little Lambs

Regulation 5.10.1.1.2: Children shall be protected from choking hazards presented by cords on window coverings, electric or electronic appliances or equipment and telephones.

“Loose electrical cords were observed accessible to children in four (4) classrooms as follows: In Ashlynn's room a cord to a light, In Alyson's room a cord to a lamp, In Melanie's room an extension cord, and in Tracey's room a cord to a sound machine. Corrective Action: Immediately ensure that electrical cords accessible to children are secured or otherwise made inaccessible to children. In the corrective action email submit photo evidence that the identified cords have been made inaccessible to children.”

Correction date in the state record: Apr 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.

“Upon review of program account information in BFIS, it was identified that a variance that had been granted allowing Staff A to act as a Teacher Associate while obtaining qualifications, had expired in January. During this visit Staff A was still acting as the Teacher Associate of their classroom and had not completed requirements to become qualified. Corrective Action: Develop a plan to ensure that each classroom is being led by a staff member who is at least qualified as a Teacher Associate for at least 75% of the hours of operation. In the corrective action email include details of how the program has come back into compliance with this rule.”

Correction date in the state record: Apr 7, 2025

Regulation 2.3.9.2: The licensee shall complete all annual licensing requirements by the anniversary date of the CBCCPP current license.

“Staff A, Staff B, and Staff C were determined to have not completed the fingerprinting renewal process based on review of BFIS accounts as well as site visit follow up with Staff D. Staff A's fingerprints expired on 5/18/23. A fingerprinting renewal letter was sent to Staff A on 3/28/23. Staff B's fingerprints expired on 5/7/23. A fingerprint renewal letter was sent to Staff B on 5/7/23. Staff C's fingerpints expired on 6/8/23. A fingerprinting renewal letter was sent on 9/8/22. Staff D confirmed via post site visit follow up that all three (3) staff have since scheduled appointments to have fingerprints completed. Corrective Action: Create a system to track staff fingerprints and when they are due. The system should include a way for staff to be alerted with reminders when fingerprinting is due in an effort to avoid fingerprints expiring.”

Correction date in the state record: Apr 8, 2024

Regulation 3.4.3: A system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the CBCCPP, shall be established. The licensee shall save all daily attendance records identifying the hours of children's attendance for at least twelve (12) months from the date that care is provided.

“Attendance in each classroom was reviewed. In [name] classroom Child A was identified by staff as being in attendance however was not signed in. In [name] room Child B was not signed in however was identified by staff as being present. Child C was identified by Staff F and Staff G as being present in [name] room just for the day due to staffing and numbers, however Child C was not signed in to [name] room. Corrective Action: Discuss with all staff challenges in ensuring children are signed in and out of classrooms at the moment of time. Once challenges are identified, create a system to address those challenges and ensure children sign in and sign out times are indicated on the attendance sheet at the time they occur.”

Correction date in the state record: Apr 8, 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.

“Staff D was observed on site but was not reflected on the Associated Parties list. Staff E reported that Staff D was present weekly and had been since October 2022. The Director confirmed that there had been a break in time that Staff D was present, but they returned in January. A record check was not received for Staff D prior to them working with children. Corrective Action: Ensure Staff D submits a record check the next time they arrive at the program or the latest by the stated due date. Ensure routine checks are done to ensure all individuals required to submit a record check to the Division are reflected on the Associated Parties list.”

Correction date in the state record: Apr 3, 2023

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.

“During three (3) observations the day of the visit, a group of twelve (12) children, with the youngest in the group being eighteen (18) months, were observed operating as one group. The maximum group size capped at ten (10) children given the age of the youngest child. Upon arrival the group was observed outdoors playing together then later returning together to the classroom. During the first classroom observation, Staff A and Staff C were observed with all twelve (12) children seated together as one group awaiting the arrival of their lunch, which Staff B was gathering. During the second observation, Staff A was observed with nine (9) children in the first portion of the room and was doing all the diaper changes, while Staff B and Staff C remained in the second portion of the classroom with three (3) children on nap mats. Staff A was observed handing children over the gate to Staff B and Staff C upon the completion of each diaper change; those children were then placed on their nap mats in the space with all the other children. When asked, Staff A stated that the group consists of thirteen (13) children typically, and they have the same schedule of activities and do those at the same time, within the same sections of the classroom. The classroom attendance reflected all children signed in as one group, and of the assigned teachers only one (1) meets Teacher Associate qualifications; an additional qualified Teacher Associate is required once the group exceed ten (10) children. The classroom had a breakdown of staff and their assigned children, however this was not observed in practice as care of children was observed and reported to occur by all staff. This is a serious violation as maximum group size was exceeded. Corrective Action: Submit a program improvement plan indicating which staff/group of staff are responsible for which children, and what the schedule will be for each group to ensure that if the group size exceeds the maximum allowed that each group has as qualified lead teacher, and the groups function independently from the other with their identified staff. Review the group size requirement with staff to ensure their understanding.”

Correction date in the state record: Mar 11, 2024

Regulation 6.2.5.10: Staff's voices shall not dominate the overall sound of the group.

“Through interviews it was shared that staff raise their voices to be louder than that of the group to gain attention, focus, or address behaviors of particular children or the group. Corrective Action: Implement techniques to use so staff do not have to raise the volume of their voice to be louder than children.”

Correction date in the state record: Apr 24, 2023

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.

“Upon review of staff BFIS Quality and Credential accounts and review of staff files found that documentation existed but was not reflected in eleven (11) staff accounts. Confirmation was received from Northern Lights at CCV that documentation was not in their queue to be uploaded to staff accounts. This is a repeat violation. Corrective Action: Review all staff BFIS Quality and Credential accounts to ensure all documentation has been submitted. Submit a program improvement plan that outlines how the program will maintain compliance to this rule. Include within this plan the system to track trainings for all current and new employees to ensure they are completed by required dates, the system on collecting training certificates or educational documents to confirm completion and qualifications, indicating who is responsible for submitting and tracking documentation to ensure it was received by Northern Lights at CCV and uploaded into staff accounts, as well as the individual responsible for communicating with Northern Lights when documentation previously submitted is not reflected in staff accounts.”

Correction date in the state record: Apr 29, 2022

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.

“Upon review of ten (10) childrens files, five (5) were missing the general health exam. Corrective Action: Ensure each enrolled child has a general health exam in their file. Develop a system to ensure that files are complete with the general health exam by the forty-fifth (45) day since a child became enrolled.”

Correction date in the state record: May 6, 2022

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.

“Upon review of the programs Associated Parties list it was determined that Staff C had not completed... Corrective Action: Ensure Staff C completes the fingerprinting process by 11/10/2020. Ensure Staff C is not left alone with children until the results of the fingerprinting process is received by the program. Develop a system to ensure ongoing compliance to this rule.”

Correction date in the state record: Dec 2, 2020