Part 2 - Allen Brook

Regulation 5.12: The licensee shall ensure that all new staff prior to working with children in the Afterschool Child Care Program; 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.

“It was confirmed that one (1) staff did not come into compliance with fingerprinting. Staff A was sent the fingerprinting letter in October 2025. Corrective Action: Have the staff make an appointment and submit to fingerprinting as soon as possible.”

Correction date in the state record: Apr 24, 2026

Regulation 5.40: Before the expiration date on the card, training for First Aid and CPR shall be validated by the American Red Cross, American Heart Association or other equivalent, state- recognized organization, and the specific certification documentation maintained in the appropriate Afterschool Child Care Program Staff file.

“It was identified that three (3) staff do not have valid first aid/CPR certification. Corrective Action: Have the identified staff complete first aid and infant/child CPR as soon as possible. Submit the completed certification to Northern Lights at CCV so that it may be entered into BFIS Quality and Credential Accounts.”

Correction date in the state record: Apr 24, 2026

Regulation 5.14: 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.

“During the visit, there were 7 staff present at the program. A review of staff BFIS quality and credential accounts and staff files reflected that one staff member had received a final clearance letter from the Division based on the results of the fingerprint supported background check. Staff A, B, C, D, E and F were all assigned to groups of children and not in ear or eyeshot of Staff G who was the only onsite staff who had received clearance from the Division. Further review of staff BFIS quality and credential accounts and staff files reflected that Staff H, I, J, K, L, and M, who have been employed with the program between 6 months and 5.5 years had not yet completed the initial and/or 5 year renewal fingerprint supported background clearance process, some including out of state records checks. While these staff members were not present at the program during this visit, they were confirmed to be active staff members of the Part 2 programs. Corrective Action: Immediately plan to consistently staff each group of children with at least one staff member who has received the final clearance letter from the Division based on the fingerprint supported background check and to ensure that no staff be left alone with children until such a time when they have received such clearance from the Division moving forward. Develop a system which will ensure all newly hired staff submit to fingerprinting and complete out of state records check paperwork as required in a timely manner moving forward. In the system, include details of: 1. who will develop and maintain the system, 2.how staff will be notified of their responsibility to complete the fingerprint supported background clearance process including out of state records check paperwork as applicable, 3. who will maintain contact with staff members to ensure these pieces are being completed in a timely manner, 4. how upper management will clearly communicate with site directors to make them aware of which staff can and can't be left alone with children, 5. how the system will track and prompt you and/or staff when it is time to begin the 5-year renewal process to ensure compliance moving forward.”

Correction date in the state record: Mar 27, 2023

Regulation 7.2: Children may be out of direct supervision within the confines of the licensed space for brief periods of time as outlined below, with Staff knowledge and permission. The chart below outlines the parameters and conditions for when a child may be out of direct supervision by Staff for short periods of time: * Grades and Age Group: Buddy Requirement; Time Limit. * Grades K, 1, and 2: With a buddy in the same age group; For not more than 10 minutes. * Grades 3, 4, and 5: With a buddy in the same age group; For not more than 10 minutes. * Grades 6 and over: No buddy required; For not more than 10 minutes.

“During the visit on 03/07/2022, Child A and Child B were playing in the gymnasium with Staff S and Staff T. Child A told Child B that the game was boring and they should leave. Child A and Child B then walked out the door to the hallway. Staff S and Staff T did not appear to notice or acknowledge that the two children had left the gymnasium. The director, who happened to be in the hallway, noticed Child A and B leaving the gymnasium and asked where they were going. Child A stated that they were bored and going to the cafeteria. The director watched them enter the cafeteria. There was no announcement over the radio system or in-person check-in between the staff in the cafeteria and the staff in the gymnasium to communicate this change. During the visit on 03/08/2022, at approximately 2:45 PM, Child A was observed to be in the cafeteria with the kindergarten group, Staff U and Staff V. At 3:54 PM, Child A entered the music room where Staff W and a group of second graders were playing. No staff were observed in the hallway or viewable vicinity at the time of Child A's arrival to the music room. No announcements were made over the radio system that indicated Child A was moving from the cafeteria to the music room. Staff W did not seem to notice or acknowledge the entrance of Child A. At 4:00 PM, Child A exited the music room to an unknown destination. Staff W did not seem to notice or acknowledge Child As departure. By the time this licensor got to the doorway of the music room, Child A was out of sight. Staff W and the group of second graders exited the music room at 4:02 PM and went to have snack in the cafeteria, stopping first at the bathrooms ro wash hands. This licensor was unable to locate Child A in any of the groups of children. At approximately 4:05 PM, when this licensor returned to check in with Staff W about the whereabouts of Child A, Child A was in the cafeteria with several of the children from Staff W's group. When asked about Child A's initial arrival to the group in the music room at 3:54 PM and then Child A's departure 4:00 PM, and return to the group in the cafeteria at 4:05 PM, Staff W stated that Child A was not originally in Staff Ws group and therefore Staff W was unsure why Child A had joined the group or where Child A was between 4:00 and 4:05 PM. When asked about the system to account for children's whereabouts, Staff V and W stated that the director typically handles that piece. Staff V and W were unable to communicate their role in keeping track of the whereabouts of children. During the debrief, the director acknowledged that several staff were having trouble keeping track of children's whereabouts and that the Director had observed several children leaving the supervision of staff without staff knowledge on 03/08/2022. Corrective Action: Immediately plan to ensure staff are providing direct supervision to every child as outlined by this regulation. In the Supervision Section of the Program Improvement Plan, describe how staff will immediately be trained and/or retrained on the program's supervision policies and systems. Include details of that system and how it may be adjusted to account for the behaviors of specific children.”

Correction date in the state record: Mar 24, 2022

Regulation 9.3: Staff shall positively model and set limits for children in areas of health, safety, and personal interactions.

“During the visit on 03/07/2022, Child E walked into the cafeteria followed by Staff W. Staff W shouted for Child E to get into the office and sit down. Once Child E was in the office, Staff W stood in the doorway of the office and continued to shout at Child E that punching Staff W in the throat and calling Staff W a bitch was unacceptable and that Child E would be going home. Child E sat at the desk in the office with a straight face and began throwing objects from the desk toward the wall, moving toward the objects that were thrown several times. Each time Child E began to move from the desk, Staff W shouted for Child E to stop and get back to the desk. When the director arrived in the cafeteria, Staff W shouted toward the director that Child E was going home because Child E had called Staff W a bitch and punched Staff W in the throat. The director, who was in the middle of deescalating a different situation with Child A and Child B, asked Staff Y to sit with Child A and Child B to continue to assist them with working through their disagreement. Staff Y moved toward Child A and Child B and stood near them. Once the director went into the office with Child E and closed the office door, Staff Y turned away from Child A and Child B who continued to shout at and shove one another. Staff Y then ignored the interactions between Child A and Child B. Children were present in the cafeteria throughout the duration of these interactions. Several children watched with eyes wide and mouths frowning. Later in the afternoon, when Child A and Child B began to use loud voices and remove items from the teachers desk in the music room, Staff W told the children that they would need to be on their best behavior because Staff W was having a really tough day. Child D then entered the music room from the hallway and threw a chair down the steps. Staff W, who was sitting at the table, shouted Child D's name. Child D went to the wall and began to kick the radiator repeatedly. Staff W, who remained sitting at the table, again shouted Child D's name. The director entered the music room to address Child D, but immediately got called to address another situation in the cafeteria. The director requested that Staff W assist and supervise Child D while Child D got dressed and gathered items to go home. Child D entered the hallway and Staff W stood in the doorway of the music room. Child D began to get boots and a jacket on, then turned and ran toward a group of children in the hallway and began kicking them. Staff W said to Child D that Child D was very capable of getting ready and the Staff W was unsure why Child D needed so much attention. The director then arrived and assisted Child D in getting ready and escorted Child D to the exit to meet Child D's parent. Later when all of the children and staff gathered in the gymnasium to discuss the activity choices and group assignments, Child A, B, and C sat together against the wall. Once everyone was seated, Staff X asked everyone to stop talking and put two fingers up in the air. All staff members and the majority of the children put their two fingers in the air and sat quietly. For approximately 15 minutes, Child A, B, and C talked loudly and laughed over Staff X as Staff X continued to hold up two fingers and say the names of Child A, B, and C repeatedly. Staff W and Staff S, who were positioned near Child A, B and C, stood with their fingers in the air. Neither Staff W or Staff S addressed Child A, B or C's behavior. After approximately 15 minutes, Staff X stated that they were going to attempt to announce activity choices and groups over the noise. Children then lined up in groups and exited the gym with assigned staff. While playing with a group of children in the gymnasium, Child F turned away from the group and toward Child A. Child F put both hands on their hips and thrusted their hips forward toward Child A. Child A smiled and backed up. Child F then pulled the front of their pants and underwear down and exposed their genital area to Child A. Child F did this several times, each time moving closer to Child A. Child A began to back away from Child F and then told Child F that this licensor was watching and Child F should stop. Child F then stopped this behavior. This licensor approached Staff T and advised them what had happened between Child F and A. Staff T stated that the children sometimes do that. Staff T then turned and walked away without approaching or addressing Child A or Child F. Corrective Action: Immediately plan to pair staff in a manner which will ensure each group of children has strong oversight by at least one seasoned staff member with the knowledge and ability to positively model and set limits for children. In the Behavior Management section of the Program Improvement Plan, include details of: 1. How staff will be assigned to specific groups, 2, A plan for staff to gain training in positive behavior management for school age children, 3. How decisions will be made in regard to assigning children to staffing pairs, 4. How staff will be made aware of the needs of the children assigned to their groups, 5. How behavior plans, IEP's, or otherwise will be disclosed to staff whom will be responsible for children who require those plans, 6. How oversight of staff will be provided in a manner which ensures sufficient support to all staff until such a time when staff members are able to appropriately, safely, and positively model and set limits for children.”

Correction date in the state record: Mar 24, 2022

Regulation 7.7: Children shall be protected at all times from the harmful acts of other children.

“During the visit on 03/07/2022, while in the gymnasium, Staff S and T attempted to gather a group of children in a circle to discuss a game that the children signed up to play. Child A and Child B ran around the circle of children, shouting, laughing, and occasionally jumping over the children in the circle. During this time Child A's and Child B's feet hit the head or face of other children they were jumping over. Staff S and T said Child A and Child B s names repeatedly and held up two fingers above their heads. This continued for approximately 15 minutes until Staff S told the children they could begin playing without instructions. Additionally, while in the music room, Child D entered the hallway just outside the music room and in clear view of Staff W. Child D walked up to a group of children who were in the hallway and began to kick them. Another school personnel, who was not a staff member of the program, was also standing in the hallway. When no program staff intervened, that school personnel firmly told Child D to stop. Child D walked into the music room. Child C then grabbed a pair of scissors off the teachers desk in the music room, held the scissors over their own head with the sharp end pointed down, and ran at another child screaming, Im a psychopath! If Child C brought the scissors down, the scissors would have struck the other child, who was less than a foot away, in the face or head. Staff W, who was sitting at the table, shouted Child C's name. Child C dropped the scissors and then immediately picked up a plastic chair with metal legs and held it over their own head and directly above the other child's body. Staff W remained sitting at the table and began to say Child C's name. The school personnel, who was previously in the hallway, was now sitting in the music room and observing the situation. That school personnel immediately stood up, moved closer to Child C and sternly told Child C to put the chair down immediately and that the behavior was unsafe and unacceptable. Child C put the chair down gently, joined the school personnel at a table and quietly engaged in putting together a puzzle with the school personnel and another child. Corrective Action: Immediately plan to ensure that Staff S, T and W are paired with other seasoned staff members until such a time when Staff S, T, and W have demonstrated a consistent ability to quickly, safely, positively and appropriately respond to children's unsafe behaviors. In the Supervision section of the Program Improvement Plan, include details of how oversight of staff will be provided in a manner that meets the level of support needed by each staff member, 2. How staff will be trained in deescalating children who are engaging in unsafe behaviors, 3. How the Positive Discipline and Behavior Management Plan will be reviewed and reimplemented in a manner which ensures children are protected at all times from the harmful acts of other children, 4. How that Positive Discipline and Behavior Management Policy may be altered or revised to include provisions for the needs of children who display behaviors that may harm other children.”

Correction date in the state record: Mar 24, 2022

Regulation 4.4: A system for taking attendance, including documentation of the time when each child arrives and departs each day he/she attends the Afterschool Child Care Program, shall be established.

“The program's attendance was not accurately documented on 8/31/2017. A child that did not arrive to the program was checked in as if the child had arrived, resulting in the child being unsupervised at another location because no one was looking for the child. Corrective Action: The program will develop and submit in writing how attendance is documented accurately to identify children arriving to the program.”

Correction date in the state record: Oct 9, 2017

Regulation 4.8.f.: Reports to the child's parent shall be made in the following circumstances: when a child who is enrolled and expected in an Afterschool Child Care Program does not arrive as scheduled, and the parent has not informed the program of the child's absence, the parent or authorized person for the child shall be contacted immediately.

“On 8/31/2017, the program did not identify that a child that was to attend the program on that day did not arrive as scheduled and therefore parents of the child were not notified. Corrective Action: The program will develop and submit in writing how they have trained their staff to identify children arriving to the program and the steps the staff shall take if a child does not arrive as planned.”

Correction date in the state record: Oct 25, 2017