Immersion Montessori School

Regulation 7.3.2: Staff The program director shall ensure and maintain documentation that staff meet one (1) of the following qualifications:

“Review of staff BFIS credential accounts reveal several staff pending credential documentation. Corrective Action: By the corrective action due date of January 30, 2026, 1. Review position qualification requirements and submit staff qualification credentials to Northern Lights 2. Respond to Licensor [name] Guertin email request for each staff members current qualification status. In the event a staff person is working on and pending a position qualification, submit a Variance Request through BFIS to request temporary approval of the staff until the position qualification is met.”

Correction date in the state record: Feb 27, 2026

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.

“It was determined monthly evacuation drills were completed in September, November and December 2025, however previous evacuation drill documentation was not located. As the record of evacuation drills was unable to be located, it is unknown what drills were completed between January and August 2025. This is a repeat violation cited in 2024. Corrective Action: For the months of January, February, March, April, May and June 2026 complete two (2) evacuation drills for each month. As of July 2026, the program may return to conducting the one (1) required evacuation drill per month. Develop a system, including who will be responsible, for ensuring a minimum of one (1) evacuation drill is conducted, documented and kept in designated location each month. Email Licensor [name] Guertin the plan developed, including a document that captures required evacuation drill data by January 23, 2026.”

Correction date in the state record: Feb 12, 2026

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.

“Review of BFIS determined two (2) staff employed over 90 days have not completed fingerprinting. Program also has new staff requiring fingerprinting. Provider did not answer to three (3) new staff employed over 30 days pending fingerprint appointments, the provider did provide fingerprint appointment dates for the two (2) staff employed over 90 days. Provider received email from Licensor [name] 11/25/25, 12/10/25, 12/12/25 with a list of staff pending fingerprint clearance. This is a repeat violation cited in 2024. Corrective Action: By the corrective action due date of January 23, 2026, create a system for tracking and ensuring that fingerprinting, when determined required, has been completed in a timely manner. Email this plan to Licensor [name] with appointment dates for three (3) new staff.”

Correction date in the state record: Jan 23, 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.

“Provider did not produce documentation that staff have completed this required training. Provider received email from Licensor [name] 11/25/25, 12/10/25, 12/12/25 with a list of staff missing this training. Corrective Action: By the corrective action due date of January 30, 2026, ensure all new staff and staff missing this training have completed it and documentation has been sent to Northern Lights. Create a system for ensuring staff will complete this training before working with children and email the plan to Licensor [name] Guertin by January 23, 2026.”

Correction date in the state record: Jan 30, 2026

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.

“Program was unable to provide evacuation drill records for the prior year. This is a repeat violation cited in 2024. Corrective Action: Create a document that captures all required monthly evacuation drill data including when regulation 3.7.2.3 will be conducted. Email Licensor [name] Guertin the document that captures the required evacuation drill data by January 23, 2026.”

Correction date in the state record: Feb 12, 2026

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

“Provider did not produce documentation that staff have completed this required training. Provider received email from Licensor [name] 11/25/25, 12/10/25, 12/12/25 with a list of staff missing this training. This is a repeat violation cited in 2024. Corrective Action: By the corrective action due date of January 30, 2026, ensure all new staff and staff missing this training have completed it and documentation has been sent to Northern Lights. Create a system for ensuring staff will complete this training before working with children and email the plan to Licensor [name] Guertin by January 23, 2026.”

Correction date in the state record: Jan 30, 2026

Regulation 7.3.1.3: The program director of a CBCCPP licensed to serve thirteen (13) - fifty-nine (59) children shall be qualified as a teacher associate, and shall have completed either: * A Vermont Early Childhood and Afterschool Program Director Step One (1) Certificate; or * Successful completion of a three (3) college credit course in program management for early care and education or for school age care and education, or in staff supervision related to early care and education of children; and a three (3) college credit course in curriculum.

“Review of staff BFIS credential account for Director pending credential documentation. Provider did not produce documentation the listed director meets qualification for their position. Provider received email from Licensor [name] 11/25/25, 12/10/25, 12/12/25 with a list of staff missing position qualification documents. Corrective Action: By the corrective action due date of January 30, 2026, 1. Review position qualification requirements for director and submit staff qualification credentials to Northern Lights 2. Respond to Licensor [name] Guertin email request for director current qualification status. In the event qualifications are pending, submit a Variance Request through BFIS to request temporary approval of the staff until the position qualification is met.”

Correction date in the state record: Feb 27, 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.

“Provider did not produce documentation staff employed over 3 months have completed this required training. Provider received email from Licensor [name] 11/25/25, 12/10/25, 12/12/25 with a list of staff missing this training. This is a repeat violation cited in 2024. Corrective Action: By the corrective action due date of January 30, 2026, ensure all new staff, staff missing this training or whose certifications have expired have completed the training and are set to receive their certification. Send documentation of completed training to Northern Lights. Create a system for ensuring staff will complete this training within 3 months of employment and email the plan to Licensor [name] Guertin by January 23, 2026.”

Correction date in the state record: Jan 30, 2026

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.

“This is a repeat violation. A violation to this rule was cited on 03/19/2025 with a corrective action due date of 04/18/2025. The original corrective action required the program to submit documentation to Northern Lights at CCV using the cover sheet, and to ensure Licensor [name] was CC'd on that email, as well as to create a system for ensuring all staff accounts are complete within six (6) months of hire as per this rule. An email was sent to the program on 04/04/2025 identifying the staff persons names and information needing to be submitted. As of 04/21/2025, the documents qualifications for three (3) of the staff persons were still not submitted. The documentation submitted as a follow up to this 04/21/2025 visit was missing the qualifications for these individuals. This is a repeat violation. Corrective Action: Ensure all outstanding documentation required to be in staff BFIS Quality and Credential accounts have been submitted to Northern Lights. Ensure when submitting those documents Licensor [name] is cc'd in those submissions. Submit a program improvement plan that identifies 1) who is responsible for collecting and submitting documentation to Northern Lights at CCV, and 2) who will monitor those submissions to ensure they are ultimately uploaded into staff accounts.”

Correction date in the state record: May 15, 2025

Regulation 2.8.1: The licensee shall post site visit reports as directed, notices of violations, or notices of regulatory action for no fewer than fifteen (15) days following receipt by the CBCCPP in a place where the information is clearly visible to parents.

“The program did not post the site visit report for the 03/19/2025 visit as required by this rule. It was confirmed that the site visit letter with violations noted was not posted within the facility either in paper form or upon the electronic notice board. Corrective Action: Post a copy of the site visit letter from 03/19/2025 and this site visit letter 04/21/2025 for the required fifteen (15) days. Send confirmation to Licensor [name] of the format and location of the posting.”

Correction date in the state record: Jun 2, 2025

Regulation 6.2.7.3: Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

“This is a repeat violation. The program was cited a violation to this rule on 03/19/2025 with required corrective action due by 04/18/2025. Staff persons were required to complete a training through the Better Kid Care website titled "See as a Child, Feel as a Child". As of 04/18/2025, no staff persons had completed the training and staff persons asked about the requirement stated they were unaware of the requirement. Corrective Action: Submit a plan for approval to Licensor [name] that includes the planned dates for each staff person to complete the required training. Include in this plan, how the training will be reviewed with staff, and the system to monitor and provide feedback to all staff resulting from observations made of them with children.”

Correction date in the state record: Jun 2, 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.

“This is a repeat violation. Seventeen (17) children ranging in age from twenty-three 23 months of age to thirty-six 36 months of age were present with two (2) staff persons during rest time. The number and ages of the children present required three (3) caregivers. The third (3) staff person was observed exiting the bulding to have their break outside.It was confirmed with staff persons present that no person was designated to replace this individual in the staff to child ratio during their thirty (30) minute break. Failing to maintain staff to child ratios during rest time was cited during a licensing visit on 03/19/2025. This is a repeat SERIOUS VIOLATION. Corrective Action: As discussed during the visit, the age of the youngest child is used in determining the ratio and maximum group size. At all times, staff to child ratios must be maintained. Supervision during rest time must meet the criteria as indicated in 6.2.3.2. which requires staff persons to remain within direct hearing distance to their assigned group of children. The corrective action required from the 03/19/2025 visit was not completed. The email required to be submitted to Licensor [name] by 04/18/2025 was to provide a breakdown of children's names, ages, group assigned and how rest time will be factored in to ensure ratios and group size are maintained, to include during times staff have their breaks. This information is to be submitted by 05/15/2025 to Licenser Crawford. A copy of the site visit report for the 03/19/2025 visit was required to be sent to every child's parent enrolled and this was not done. Because of failure to complete previously required corrective action, the serious nature of the violation, and the repeat nature of this violation, the program is required to complete the following by 05/15/2025: Send a copy of the 03/19/2025 site visit letter and this 04/21/2025 site visit letter to all parents of children enrolled in care between 03/19/2025-04/21/2025. Submit the names of the children, names of the parents, and the contact information for the parents to Licensor [name]. Train all staff persons on rules relating to staff to child ratios and rest time practice regulations. Submit to Licensor [name] what was covered with staff and documentation with staff signatures confirming they are aware of the requirements of this rule.”

Correction date in the state record: May 15, 2025

Regulation 5.8.2: Staff shall ensure that if an accident or injury occurs to a child, while in attendance, immediate action is taken to protect the child from further harm and notification of the child's parents as quickly as possible.

“This is a repeat violation. The program was cited a violation to this rule during a site visit on 03/19/2025. The program was required to update the staff handook regarding the requirements for filing incident reports and notification to the family requirements. The due date for this corrective action was 04/18/2025. It was confirmed during this visit on 04/21/2025 that the required corrections had not been completed. Corrective Action: Review this rule with all staff to ensure their understanding, and update the staff handbook with the expectations on filing an incident report and notifying the family. Send the update staff handbook and documentation confirming each staff person has been trained upon the incident procedure to Licensor [name].”

Correction date in the state record: May 15, 2025

Regulation 6.2.7.3: Staff shall use positive methods of guidance and behavior management that encourage self-control, self-direction, self-esteem, and cooperation.

“Upon review of video footage from 1/30/25, Staff A is observed grabbing at Child B's upper right arm as Child B sat at table with their peers. Child B is observed pulling away from Staff A. Staff A is not heard speaking to Child B to request them to move, or to transition to another activity. Staff A is then observed grabbing Child B's left hand and pulling in an upward motion. Child B is observed falling to the ground and immediately is seen holding their left wrist and crying. Staff A is observed throwing their own hands above their head while Child B walks off screen to a different area of the room. Staff A is observed sitting in the chair and then approaching the area Child B went. Additional video footage showed Staff A taking food from a different child, and putting their lunch box away. There was no discussion about the child still eating or willingness to cooperate and move on to another activity. Throughout the review of video footage children were observed eating at their will; there was no explanation to this child why they were no longer able to eat, other than they stepped away from the table with food. The child was not re-directed or given a warning. Corrective Action: Review this rule with all staff, and ensure their understanding. Ensure all staff complete the training through Better Kid Care "See as a Child, Feel as a Child"; provide completion certificates for each staff by the identified due date. Develop a system to monitor staff to ensure compliance with this rule. Confirm in the corrective action email that this has been reviewed with staff, and the system to monitor and provide feedback to all staff resulting from observations made of them with children.”

Correction date in the state record: May 15, 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.

“Fifteen (15) children were with one (1) staff during rest time, to include a twenty-eight (28) month old child. One (1) additional staff within hearing distance indicated they had not been working in a classroom, rather doing Director duties, the other staff in the building was assigned to another group of children in a different classroom, and the final staff was on break outside of the building. This is a SERIOUS VIOLATION. Corrective Action: As discussed during the intial debrief, the age of the youngest child is used in determining the ratio and maximum group size. Ratios must be maintained during rest time as indicated in 6.2.3.2. In the corrective action email, provide a breakdown of children's names, ages, group assigned and how rest time will be factored in to ensure ratios and group size are maintained, to include during times staff have their breaks. A copy of this report is required to be sent to every child's parent enrolled. Provide Licensor [name] a list of children's names, their parents name and contact information once the report has been provided to them.”

Correction date in the state record: May 15, 2025

Regulation 5.8.2: Staff shall ensure that if an accident or injury occurs to a child, while in attendance, immediate action is taken to protect the child from further harm and notification of the child's parents as quickly as possible.

“Upon review of video footage of 1/30/25 and through discussions with staff, a child was injured at 9:30 am. The child was observed holding their arm and was minimally engaged with their peers with use of only one (1) arm during play. Staff were observed acknowledging the child holding their arm at points during open play. The child's family was not informed of this injury until approximately five (5) hours after it occurred. The child required medical attention and this was delayed as a result of the family not being aware. Corrective Action: Review this rule with all staff to ensure their understanding, and ensure the staff handbook outlines the expectations on filing an incident report and notifying the family when applicable in addition to the written report.”

Correction date in the state record: May 15, 2025

Regulation 3.2.1: Serious injury or death of a child: The licensee shall make a timely report to the Division of any injury or accident involving an enrolled child resulting in in-patient or out-patient medical or dental treatment or death. In the event of a death, a verbal report shall be made immediately followed by a written report within twenty-four (24) hours. In the event of an injury or accident resulting in in-patient or out-patient medical treatment, a verbal report shall be made within forty-eight (48) hours and the written report shall be made within five (5) business days.

“A child was injured in care and required medical attention the same day. The program was aware the injury occurred on site, and that the child received medical attention. The program did not notify the Division as required by this rule. Corrective Action: Ensure there is a system to notify the Division as required by this rule. In the corrective action email, indicate who will be the individual responsible for this notificication.”

Correction date in the state record: Apr 11, 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.

“A review of BFIS and on-site files was done to assess staff qualifications related to a concern brought forward to the Division. Documentation required to be in staff quality and credential accounts was not in place for this assessment to be completed. Once the corrective action has been completed a focus compliance visit will be conducted to further assess the original concern that staff are not qualified for their positions. Corrective Action: Submit education documentation for all staff who have not been deemed qualified for the position they serve, as well as all other required documentation related to professional development and required trainings. In the submission of those documents to Northern Lights at CCV cc: Supervisor Sheldrick-Humphries. In the corrective action email, identify the system the program has implemented to maintain compliance with this rule.”

Correction date in the state record: May 15, 2025

Regulation 6.2.6.6: The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

“Upon arrival to the program the two (2) operating classrooms each had staff alone with children who had not been cleared to do so. The Director confirmed that prior to our arrival they had not been in a classroom and had been conducting Director duties in the office. Upon review of previous weeks staff attendance in each classroom, it was found that staff were alone with children and were not cleared to do so in the Nido classroom on 3/3/25, 3/5/25, 3/6/25, and in the Casa classroom on 3/4/25. Additional days in each classroom found times throughout additional days that coverage was provided by staff not cleared to be alone with children. This is a repeat violation. Corrective Action: As discussed during the initial debrief, ensure each group of children has someone who has been cleared through the entire background clearance process with them at all times. In the corrective action email provide the staffing pattern, to include breaks that confirms compliance with this rule.”

Correction date in the state record: May 15, 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.

“Conversation with Staff A determined drills were completed in June and July 2024, however not in August or September 2024. As the record of evactuation drills was unable to be located, it is unknown what drills were completed between October 2023 and May 2024. Corrective Action: For the months of November and December 2024, and January , February, and March 2025 complete two (2) evacuation drills for each month. As of April 2025, program may return to conducting the one (1) required drill per month. Create a system for ensuring the drills are conducted.”

Correction date in the state record: Nov 13, 2024

Regulation 6.2.6.6: The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

“At the time of this visit no staff members present have been cleared by the background check process. This is a repeat violation. Corrective Action: Submit a program plan for ensuring a staff member who has been cleared through the background process is present at all times, and ensuring that no staff not yet cleared are not left alone with children. By the corrective action due date provide receipts to show fingerprinting has been completed for all staff.”

Correction date in the state record: Nov 15, 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.

“Inspection of the playground found the climbing dome did not have adequate cushioning material as required by this rule. Children were observed climbing on the dome, placing them higher than thirty (30) inches. Corrective Action: Ensure cushioning material meeting all the requirements of this rule is put in to place. Until such time, immediately ban children's access to the dome.”

Correction date in the state record: Nov 13, 2024

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.

“Review of BFIS determined Staff O was due to complete new fingerprinting by April 2023. Staff O was advised of this in a letter generated and issued 3/15/23. Staff O submitted the required Records Check Authorization on 1/19/24 at which time a letter advising of fingerprinting was issued. As of this date fingeprinting for Staff O has not yet been completed Corrective Action: By the corrective action due date submit a receipt showing that fingerprinting has been completed for Staff O.”

Correction date in the state record: Nov 14, 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.

“Review of BFIS accounts for all staff as well as staff files on site, determined Staff E, Staff G, Staff H, Staff I, Staff J, and Staff K have not completed this required training. Corrective Action: Ensure all Staff identified as missing this training complete it by the corrective action due date.”

Correction date in the state record: Dec 10, 2024

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.

“Program was unable to provide evacuation drill records for the prior year. Corrective Action: Create a system for ensuring drills are recorded when completed, including finding a location where the record can be easily accessed.”

Correction date in the state record: Nov 13, 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.

“During this visit Staff L, Staff M, and Staff N were present and working in the classrooms with the children although they are not on the program's Associated Parties list. It was also identified based on BFIS review that fingerprinting is outstanding for Staff A, Staff B, Staff D, Staff E, Staff F, Staff K, and Staff P. In addition, Staff E has not provided the Division with the required Out of State paperwork sent to them.This is a repeat violation. Corrective Action: Submit Records Check Authorization forms for the three (3) identified individuals. Until Records Check Authorizations have been processed and staff are showing on Associated Parties list, ensure they are not present or working at the program. Create a program plan to ensure ratios are maintained using only the staff on the Program's Associated Parties list.”

Correction date in the state record: Nov 27, 2024

Regulation 3.4.7.5: The licensee shall maintain a current list of the licensee or designee, staff, auxiliary staff, and volunteers as in the rules in section 7.7.5 of these regulations, as applicable in BFIS. Any changes shall be reported through BFIS within five (5) working days of the change.

“Review of Associated Parties list with Staff A during this Licensor's visit determined list is not up to date as five (5) staff were identified as no longer working at the program as of the end of summer programming. Corrective Action: Enter end of employment dates for all staff no longer employed at the program. Create a system for ensuring BFIS is updated going forward within five (5) days of the change.”

Correction date in the state record: Nov 14, 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.

“Review of BFIS Credential accounts determined Staff D, Staff E, and Staff F, all identified during the visit as working being counted in ratio and/or left alone with children, had not yet completed this training. The three (3) staff have all been employed at the program for more than three (3) months. Credential review also revealed Staff B's certification expired 8/27/23, and Staff C's expired 12/31/21. Corrective Action: By the corrective action due date ensure all staff missing this training or whose certifications has expired have completed it and are set to receive their certification.”

Correction date in the state record: Nov 13, 2024

Regulation 6.2.6.6: The program director shall ensure that no person be left alone with children without approval from the Division based on the results of a background check that includes fingerprinting; with the exception of a parent may be left alone with his/her own child(ren).

“Upon arrival at the program, Staff B, Staff C, and Staff D were observed to be on the outdoor playspace with a group of eighteen (18) children. Review of Associated Parties list determined none of these three (3) staff had been cleared by the Division's background check process. Staff A, the only staff member present who has been cleared by the process, was inside the building unable to see or hear the outdoor playspace. Corrective Action: Create and submit a plan to this Licensor detailing how the program will ensure that staff who have been cleared to be alone with children are in each group and remain in the groups until further staff are cleared.”

Correction date in the state record: Nov 13, 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 A identified Staff B, Staff C, and Staff D as being the staff present in the Casa classroom. Staff A identified Staff Y and Staff Z as being present in the Nido classroom. Review of Associated Parties list as of 7/23/24 determined none of the five (5) staff identified by Staff A were on the list. Corrective Action: Immediately discontinue using any staff that have not submitted a Records Check Authorization. Provide a plan to this Licensor on how ratios will be maintained using only staff who have submitted their Records Check Authorization forms. Provide a plan for ensuring Records Check Authorization forms are submitted prior to working with children.”

Correction date in the state record: Nov 13, 2024

Regulation 5.10.1.1: General Safety: The licensee shall ensure the physical facilities of the CBCCPP, grounds, equipment, and toys present no hazard to the health, safety, and well-being of the children.

“Department of Fire Safety as well as Staff A from the program identified and confirmed children were present at the same time construction was being done to expand the program's bathroom. It was confirmed the construction caused levels of dust resulting in the fire alarms going off. It was determined by DFS a increase in the carbon monoxide levels occurred due to the use of gas powered equipment, although they did not rise high enough to set the CO2 alarms off. Children were evacuated immediately upon the setting of the fire alarm. Corrective Action: Submit a program procedure on how any construction or maintainance work will be completed going forward while ensuring children are not put at risk or exposed to hazards in accordance with this rule.”

Correction date in the state record: Jul 3, 2024