ST. Monica - ST. Michael School

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 citation of this violation due to failure to complete the required action from when the violation was initial cited during a visit on 02/19/2025. Three (3) staff members need to submit their CPR and First Aid training to their BFIS credential account upon completion. Corrective Action: The corrective action originally required to be completed by 03/19/2025 still needs to be completed. Submit unrecorded classes and trainings to Northern Lights. Develop a system with your staff, to ensure that they are submitting the correct/required documents of trainings and qualifications to BFIS on an ongoing basis throughout the year.”

Correction date in the state record: Sep 8, 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.

“All CPR, First Aid and other trainings need to submitted to each staff members BFIS credential account upon completion. I was able to observe several certificates and trainings that had not been uploaded yet. Corrective Action: Submit unrecorded classes and trainings to Northern Lights. Develop a system with your staff, to ensure that they are submitting the correct/required documents of trainings and qualifications to BFIS on an ongoing basis throughout the year.”

Correction date in the state record: Sep 8, 2025

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 program has not submitted a report to Vermont Department of Health certifying that IRC's have been completed in the last year. Corrective Action: Ensure that IRC's are completed and a certification filed with Vermont Department of Health on your building.”

Correction date in the state record: Jun 19, 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.

“A review of staff BFIS credential accounts and staff files reflected that Staff C and F had not yet completed an approved orientation training. Staff C and F hold position titles which allow them to be counted in ratio and left alone with children. Staff C was counted in ratio and left alone with children during this visit. Staff C and F have been employed by the program for at least five months. Corrective Action: Immediately plan to have Staff C and F complete an approved OrientationTraining and submit the certificate of completion with cover sheets to Northern Lights at CCV by 01/26/2024. Include in the Staff Training and Documentation portion of the program improvement plan details of who will be responsible for communicating this requirement to all staff, what system will be utilized to track staff compliance with this rule, and who will be responsible for ensuring all newly hired staff as outlined in this rule complete an approved orientation training within 30 days of hire and prior to being counted in ratio or left alone with children, and who will ensure all certificates of completion are submitted with cover sheets to Northern Lights at CCV in a timely manner moving forward.”

Correction date in the state record: Jan 27, 2024

Regulation 5.2.1.2: The program director shall ensure that adults also wash their hands: * Before and after giving medications; * Before and after caring for a child who is injured or may be sick; * Before diapering; and * After coming into contact with blood, fecal matter, urine, vomit, nasal secretions or other body fluids.

“During the visit, it was noted that at least eight children were permitted to use hand sanitizer after returning from outdoor play and prior to eating lunch. This does not meet the requirements of this rule. Corrective Action: Immediately plan to ensure all children and adults wash their hands with warm running water and soap as described in this rule. Per rule 5.2.1.4, hand sanitizer is only an allowable option when soap and warm running water are not available. In the Health section of the program improvement plan, include details of the newly implemented system which ensures all staff and children are aware of the requirement to wash hands with soap and water and who will be responsible for ensuring follow-through at each required time as noted in this rule moving forward.”

Correction date in the state record: Jan 27, 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.

“A review of staff files and staff BFIS credential accounts, reflected that Staff A, B and C had not yet completed infant and child CPR and pedicatric first aid certifications. Staff A, B and C have been employed by the program since August of 2023 and hold position titles which allow for being counted in ratio and left alone with children. Corrective Action: Immediately plan to have Staff A, B and C complete approved infant and child CPR and pediatric first aid certifications by 01/26/2024. A variety of online only certification courses are still available and acceptable at this time. To find that list, you may visit the Northern Lights at CCV website. In the Staff Training and Documentation portion of the program improvement plan, include details of who will be responsible for notifying staff of their responsibility to become certified within three months of hire and remain currently certified thereafter, which system will be utilized to track staff certifications and due dates, and who will be responsible for ensuring staff are completing certifications within three months of hire and prior to the certificate expiry, and submitting the certificates of completion with cover sheets to Northern Lights at CCV in a timely manner moving forward.”

Correction date in the state record: Jan 27, 2024

Regulation 3.7.1.2: The licensee shall ensure that all staff are trained on the Emergency Response Plan and are aware of where to find the written plan in the CBCCPP.

“During the visit, staff testimony reflected that the emergency response plan is made available to all staff upon hire. The program has an already established system to have staff read the plan, ask questions and sign a document stating their understanding of the plan. However, the program is not currently utilizing that system or any other system to ensure staff are properly trained on the Emergency Response Plan as required. Corrective Action: Immediately plan to properly and formally train all staff on the emergency response plan for the program by 01/26/2024. In the Staff Training and Documentation section of the program improvement plan, include details of the system which will be used to ensure current and any newly employed staff are formally and properly trained on the Emergency Response Plan and who will be responsible for implementing this training upon hire moving forward.”

Correction date in the state record: Jan 27, 2024

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.

“A review of staff BFIS credential accounts and staff files, reflected that no current representative of the licensee had taken an approved emergency preparedness training. The director of program has been appointed such since October of 2020. Corrective Action: Immediately plan to have the representative of the licensee complete an approved emergency preparedness training by 01/26/2024. One option for an approved training can be found on the FEMA website and is titled, "Preparedness for Child Care Providers" ; https://training.fema.gov/is/courseoverview.aspx?code=IS-36.a&d=10/1/2021&lang=en. Other approved options may be found by visiting the Northern Lights at CCV web page and training calendar. In the Safety portion of the program improvement plan, include details of who will b responsible for taking an approved training and utlizing the training as a resource to review and update the current Emergency Response Plan for the program.”

Correction date in the state record: Jan 27, 2024

Regulation 6.2.4.4: The program director shall ensure that a staff member who is at least qualified as a teacher assistant is present while children are present at the CBCCPP.

“During the visit, Staff B stated that they regularly work with the children for the afterschool portion of the program when the regular staff leave for the day. Staff B stated that Staff F typically works with them each afternoon. Neither Staff B or F are qualified as at least a teacher assistant. This does not meet the requirements of this rule. Corrective Action: Immediately plan to ensure that a staff member who is at least qualified as teacher assistant is present while children are present at the program. In the Safety portion of the program improvement plan, include details of the new staff schedule which ensures compliance with this rule moving forward.”

Correction date in the state record: Jan 27, 2024

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

“During the visit, it was observed that a container of clorox disinfecting wipes and multiple bottles of hand sanitizer were stored at children's reach. One child was observed to pick up a bottle of hand sanitizer and use it on their own hands and then squirt it onto the hands of multiple other children. These items were all noted to have labelling stating: "Keep Out of Reach of Children". Corrective Action: Immediately plan to store all materials required for routine cleaning in a safe manner and out of reach of children. In the Safety section of the program improvement plan, include details of where routine cleaning materials will be stored and who will be responsiible for making all staff aware of these requirements and ensuring follow-through moving forward.”

Correction date in the state record: Jan 27, 2024

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 credential accounts and staff files reflected that required documents for the Director, Staff B, E and F had not submitted in a manner which ensures compliance with this rule. the Director and all three listed staff have been employed by the program for at least six months. Corrective Action: Immediately plan to submit all required documentation with cover sheets to Northern Lights at CCV for all listed staff by 01/26/2024. In the Staff Training and Documentation portion of the program improvement plans, include details of who will be responsible for notifying all staff of this requirement, who will track the submission of required documents and regularly check staff BFIS accounts to ensure document upload, and who will communicate with Northern Lights at CCV when documents are not uploaded as expected moving forward.”

Correction date in the state record: Jan 27, 2024

Regulation 5.10.2.3.2: The CBCCPP shall ensure that perishable food provided by home is stored in insulated lunch boxes with at least two (2) ice packs. The CBCCPP shall ensure that perishable food provided by home is stored in a refrigerator as specified in the rule 5.10.2.3.1 of these regulations when the perishable food is not stored in an insulated lunch box, and/or not stored with at least two (2) ice packs.

“During the visit, it was observed that children's lunchboxes contained perishable items, such as chicken, dairy products, and lunch meat and did not contain at least two ice packs. Most observed lunchboxes contained zero ice packs. All children's lunchboxes are stored at room temperature. Corrective Action: Immediately plan to store all children's perishable items in individually labelled containers in a refridgerator or to ensure parents are sending lunchboxes with at least two ice packs when perishable items are included. In the Safety section of the program improvement plan, include details of how the program will either: 1. provide a refriedgerated space for children's perishable items, or 2. communicate the requirements of this rule with parents and ensure follow-through moving forward.”

Correction date in the state record: Jan 27, 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.

“A review of staff BFIS credential accounts and staff files reflected that Staff C, D and E had not yet completed the required Mandated Reporter Training; Protecting Vermont's Children: Reporting Abuse and Neglect. Staff C and D hole position titles which allow them to be counted in ratio and left alone with children and have been with the program for at least five months. Staff C was left alone with children during this visit. Staff D stated that they are left alone with children during the afternoon protion of the program. Staff E is an auxiliary staff and has been with the program for more than two years. Corrective Action: Immediately plan to have Staff C, D, and E complete the required Mandated Reporter Training and submit the certificate of completion with cover sheets to Northern Lights at CCV by 01/26/2024. Include in the Safety portion of the program improvement plan details of who will be responsible for communicating this requirement to all staff, what system will be utilized to track staff compliance with this rule, and who will be responsible for ensuring all newly hired staff as outlined in this rule complete the required mandated reporter training within 30 days of hire and prior to being counted in ratio or left alone with children, and who will ensure all certificates of completion are submitted with cover sheets to Northern Lights at CCV in a timely manner moving forward.”

Correction date in the state record: Jan 27, 2024

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.

“During the visit, it was observed that multiple cords were not secured and were accessible in areas where children were playing. The accessible cords were noted in both preschool classrooms and included; cords to phones, fans, computers, speakers, and one long green extention cord. Corrective Action: Immediately plan to secure all cords which may present a choking or strangulation hazard. In the Safety section of the program improvement plan, include details of who will be responsible for routine classroom checks to ensure cord safety, how often those checks will occur, who will be responsible for addressing all identified cord safety issues prior to children using the space each day moving forward.”

Correction date in the state record: Jan 27, 2024

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.

“A review of staff BFIS accounts and staff files reflected that the Director and Staff D had not completed 15 hours of annual professional development based on their start dates. Staff D had completed eleven hours of professional development and the Director had completed zero hours of annual professional development. Corrective Action: Immediately develop a plan to have the Director complete a total of 30 hours of annual professional development and for Staff D to complete a total of 19 hours of annual professional development for the current year based on start dates, and to submit the certificates of completion with cover sheets to Northern Lights at CCV in a timely manner. Include in the Staff Training and Documentation portion of the program improvement plan details of who will be responsible for communicating this requirement to all staff, what system will be utilized to track staff compliance with this rule, and who will be responsible for ensuring all newly hired staff complete the required fifteen hours of annual professional development based on start date, and who will ensure all certificates of completion are submitted with cover sheets to Northern Lights at CCV in a timely manner moving forward.”

Correction date in the state record: Jan 27, 2024

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.

“During the visit, the evacuation drill log indicated that no evacuation drills were conducted for the months of November and December of 2023. Staff testimony supported that these drills had not occured. Corrective Action: Immediately plan to conduct and record two evacuation drills for the months of January and February 2024. In the Safety section of your program improvement plan, include details of who will be responsible for scheduling, conducting and recording two evacuation drills for the months of January and February 2024 and then one evacuation drill per month moving forward.”

Correction date in the state record: Jan 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.

“A review of the BFIS program Staff List reflected that four individuals listed at the time of the visit had not been working with the program for at least 30 days. This does not meet the requirements of this rule. Corrective Action: Immediately plan to remove the four inactive staff from the BFIS staff list by 01/26/2024. In the Staff Training and Documentation portion of the program improvement plan, include details of who will be responsible for updating the BFIS Staff list within five days of any change moving forward.”

Correction date in the state record: Jan 27, 2024

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.

“It was identified that six (6) staff who have been employed for more than 30 days, have not completed an approved orientation training. Three (3) of the six (6) staff have not completed an approved mandated reporter training. Corrective Action: By 4/14/2023, all staff currently working at the program who have not completed an approved orientation training and/or an approved mandated reporter training shall complete those trainings and submit certificates as appropriate to Northern Lights at CCV. Create a system to ensure that all staff will complete a full orientation training to include an approved orientation training, and an approved mandated reporter training prior to being left alone with children, and within the first month of employment.”

Correction date in the state record: Mar 21, 2023

Regulation 5.4.1.8: Bedding used by a child shall be stored in a manner that prevents contact with bedding used by other children.

“Bedding used by children in both preschool classrooms are stored in the bottom portion of the cubbies. The bedding is not contained in bags or storage containers so that one child's bedding can touch another child's bedding. Corrective Action: Effective immediately, store children's bedding in individual bags or store in a way that prevents the bedding from touching as discussed.”

Correction date in the state record: Mar 21, 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.

“Three (3) staff who have been employed for more than three (3) months, have not completed pediatric first aid and CPR certification as required. Corrective Action: Have staff complete pediatric first aid and CPR certification and maintain certification. Create a system where new staff complete the pediatric first aid and CPR course within three (3) month of their hire date.”

Correction date in the state record: Mar 21, 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.

“After a review of BFIS Quality and Credential accounts and discussion with the program director, it was determined that nine (9) staff employed longer than six (6) months did not have up to date BFIS Quality and Credential Accounts as required. This is a repeat violation previously cited on 9/28/20. Corrective Action: By 4/10/2022, submit missing documentation for qualifications and/or trainings to Northern Lights at CCV with the required cover sheet. The Verification Cover Sheet can be found at: https://northernlightsccv.org/resource/verification-cover-sheet/. Create a program improvement plan that will include strategies to ensure that staff BFIS Quality and credential are maintained up to date moving forward. Submit a copy of the plan and confirmation to your licensor kimberlie.buxton@vermont.gov that all required information has been sent to Northern Lights at CCV.”

Correction date in the state record: Mar 24, 2022

Regulation 3.4.7.3: Within six (6) months of the initial date of employment; staff and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations, and the program director shall maintain an up-to-date BFIS Quality and Credential Account. Documentation, verification of qualifications, and all annual professional development activities as specified in the rules in sections 7.3 and 7.4 of these regulations shall be submitted to Northern Lights at CCV to be verified and maintained in BFIS.

“After a review of staff Quality and Credential accounts and onsite files, it was determined that 7 staff at the program did not have up to date Quality and Credential accounts as required. This is a violation because one or more documents may have been missing from staff Quality and Credential accounts that includes but is not limited to: qualification documentation, proof of required trainings such as Orientation, Emergency Response Plan Training, or Mandated Reporter training and annual professional development. This is a violation because all items related to qualifications, required trainings, and annual professional development is required to be kept up to date in each staff member's BFIS account. Corrective Action: By 10/21/2020, it is required to develop a plan to review each staff member's BFIS Quality and Credential account to determine what is required and what may be missing and a plan for how the accounts will be updated. Strategies for keeping Quality and Credential Accounts up to date in BFIS should also be included in the plan. This plan may be sent via email to licensor [name] Smith for review.”

Correction date in the state record: Oct 15, 2020