Warren KPAS

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.

“One (1) staff was missing CPR/First Aid training in BFIS. Director stated they were supposed to take the training on 4/3/2026, but staffing issues precluded them from attending. On 4/14/2026 Director emailed Licensor with a new registration date of 4/17/2026. Corrective Action: Submit staff's completed CPR/First Aid training certificate to Northern Lights and send submission confirmation to the licensor by 4/21/2026.”

Correction date in the state record: Apr 21, 2026

Regulation 5.1.4: The licensee shall submit a Vermont Child Care Immunization Report at least once every 365 days to the Vermont Department of Health, Immunization Office as required by 18 V.S.A. SS 1120 - 1129.

“The required annual immunization survey was not submitted to Vermont Department of Health by midnight on 12/31/25. Initial notification of this requirement was sent the beginning of November, with reminders provided weekly, then daily, closer to the due date. Corrective Action: You must submit the past due 2025 annual immunization survey to Vermont Department of Health by midnight on 1/14/26. Failure to submit this survey will result in further regulatory action. Additionally, submit a statement to Kristy.Haapala@vermont.gov indicating who will be responsible for submitting this survey in the future. Status: Appeal Period.”

Correction date in the state record: Jan 16, 2026

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“Three (3) staff listed on the associated parties list at the time of the visit do not have First Aid and CPR training certificates in BFIS or on site. The director stated that one(1) of the staff on that list no longer works at the program but she did not remove them from the associated parties list. That staff member left employment less than a year ago and there was no staff file on site as required to verify if they had completed this training. After the visit one staff member's First Aid and CPR certificate was submitted and reflects that the staff member had valid First Aid and CPR certification at the time of the visit. When certificates are not available during or provided immediately after the licensing visit it is assumed that staff have not completed the training, licensing must issue the site visit report in a timely manner and cite violations based information that was available at the time the report was generated. This is a repeat violation previously cited on 12/20/2023 Corrective Action: By the corrective action due date email the certificates of current staff who have been employed for more than three(3) months to Northern Lights at CCV and include this licensor. Work with the SPARQS Quality Support Specialist to create a plan for how the program will maintain future compliance with this regulation.Failure to submit the certificates by the due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 5.2.6.4: Cleaning of the following items shall be done on the following schedule: After each use: * Countertops; * Food preparation appliances; * Plastic mouthed toys; * Changing tables; and * Cribs, cots, mats, and bedding, if used by different children. When it touches another surface: * Pacifiers Every Day: * Uncarpeted floors Every week: * Cribs, cots, mats, and bedding if used by the same child every day. Every month: * Machine washable toys; * Dress-up clothes including hats; * Play activity centers; and * Refrigerator.

“Children's bedding is not washed weekly. When asked the director was not sure when the last time bedding was washed. Corrective Action: Immediately ensure bedding and linens used by children at rest time are laundered weekly. Email this licensor identifying if the program will wash the bedding weekly or send it home with families at the end of the week. Identify which staff member will be responsible for ensuring bedding and linens are washed each week. Failure to complete corrective action requirements by the due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 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.

“The director stated they have not recorded fire evacuation drills for the months of September,October and November. It is likely that the program participated in a building wide fire evacuation drill but that can't be confirmed as no log was kept. This is the fourth time a violation related to fire evacuations has been cited, 05/18/2018, 01/31/2022 and 12/20/2023. When the violation was cited in 2023 the director was notified that the Division of Fire Safety would be contacted if there was future non compliance with this regulation. The Division of Fire Safety will be informed of the program's pattern of non compliance with fire safety regulations. Corrective Action: The program will conduct two(2) drills during the months of January and February. The director is required to work with a SPARQS Quality Support Specialist to develop a program improvement plan that will identify how the program will maintain future compliance with this regulation.The plan will include a template evacuation log, identify who is responsible for filling out the form after evacuations and will identify the location where the log will be kept The director will communicate progess with this licensor, the program improvement plan will be reviewed by this licensor in a follow up licensing visit. Status: Appeal Period.”

Correction date in the state record: Jan 21, 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.

“Three(3) staff members have been employed for six months and do not have up to date BFIS Quality and Credential accounts. Corrective Action: By the corrective action due date all missing documents must be submitted to Northern Lights at CCV so they can be uploaded into BFIS. Include this licensor on the email submissions. Work with the SPARQS Quality Support Specialist to create a system that will ensure training documents are sent to Northern Lights at CCV within the required timeframe and any other steps that will ensure the director has a system for monitoring staff BFIS acounts. Failure to submit the missing documents by the due date will result in licensing action that will place the license in provisional status. An email was sent to the director on 12/22/2025 listing the documents that are missing. Please also ensure you are sending the documents for the staff member that started in June of 2024 but was added to the associated parties after this licensing visit. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

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.

“Staff are placing all of the children's bedding and linen used during rest time in one large laundry bin. As noted in a seperate violation, not only are the bedding and linen all stored together, they are not washing them weekly. Corrective Action: Immediately stop placing children's bedding and linens in a container together. Store the bedding and linens in a manner in which they are not touching. Send a picture of the bedding storage arrangement.Failure to complete corrective action requirements by the due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 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.

“At the time of the visit five(5) staff members listed on the associated parties list as current staff, did not have documentation on site or in BFIS to support they have completed the approved mandated reporter training. The director emailed one of the missing certificates to this licensor after the visit. It should also be noted that the director stated that three(3) of the five (5) staff members noted on this report were no longer working at the program but she did not remove them from the associated parties list. They are included in this violation because it is required that after a staff member leaves employment a copy of their file is kept for one year. The three(3) staff members that Amanda states no longer work at the program did not have mandated reporter certificates on site or in BFIS indicating they did not complete this training. This is a repeat violation that was previously cited on 02/19/2020. Corrective Action: By the corrective action due date submit the missing mandated reporter training certificates for current staff only(I emailed the director identifying who they are) to Northern Lights at CCV and include this licensor on that email. Failure to submit the missing certificates by the corrective action due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 3.4.4.1: The program director shall maintain a complete and up-to-date enrollment file on-site for each child enrolled in the CBCCPP. A complete file shall contain, at minimum, the following information: A completed child's admission form signed and dated by the parent that includes the first date the child attended the CBCCPP and the days and hours the child is regularly scheduled to attend the CBCCPP; The child's name, current home address, and current home telephone number; Identification of child's home language; The child's date of birth; Name, address, and all applicable current telephone numbers for parents; Name, address, and all applicable current telephone numbers for at least two (2) other people designated by the parents as emergency contacts; Names for all persons authorized to pick the child up from the CBCCPP; Record of an annual physical and health history as required in the rule 5.1.2 of these regulations that includes the name and telephone number of the child's primary health care and dental care providers (if the child has a dental care provider); A description of any special medical, developmental, emotional, or educational needs of the child including allergies, existing illnesses or injuries, previous serious illnesses or injuries and any prescribed medication including those for emergency situations; Written authorization from the parent for the CBCCPP to be able to obtain emergency medical care and transportation; Child's immunization record or Vermont Department of Health approved exemption document as required in the rules in section 5.1.3 of these regulations; Written permission from parents for the CBCCPP to transport the child, if transportation is provided, as required in the rule 5.10.6.6.1 of the regulations; Written permission from parents for the child to participate in swimming activities, if swimming activities are a part of the program, as required in the rule 5.10.5.1 of these regulations; If applicable, a copy of court orders on custody and visitation arrangements as required in the rule 3.6.4 of these regulations; and If applicable, any obvious injuries discovered and documented on daily health check as required in the rule 5.3.2 of these regulations.

“The director provided this licensor with a folder that contained seven(7) sheet of paper. Each sheet had the child's name, parent information and days they are attending. I asked her where the rest of the files were as there were more than seven(7) children present. She stated that she may have some documents on her computer, however the computer was no on site. Each child's immunization and well health examination documents were kept in seperate folders. The files that were provided were incomplete and each was missing more than 50 % of the required documents listed in this regulation. Corrective Action: By the corrective action due date submit an intake with the SPARQS program requesting mentoring support. Work with the SPARQS Quality Support Specialist to create child files and create an enrollment packet that includes all of the required information outlined in regulation 3.4.4.1. Email this licensor once all children's files are complete, this will require having all families fill out the new enrollment form. During a follow up licensing visit this licensor will review all children's files. Failure to submit an intake with SPARQS by the corrective action due date will result in licensing action that places the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

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.

“At the time of the visit there were three(3) staff members listed on the BFIS associated parties list that no longer worked in the program. In June of 2025 Licensing Supervisor [name] spoke with the director and provided her with information on how she could go into BFIS and remove staff who were no longer working at the program. Corrective Action: On 01/07/2025, the date this report was generated,those three(3) staff members are still listed as staff on the associated parties list. During the licensing visit this licensor asked the director to remove former staff. By the corrective action due date please remove any staff no longer working at the program. Email and confirm with this licensor that the BFIS associated parties list is up to date and former staff have been removed. Failure to complete corrective action requirements by the due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

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.

“The bathroom located within the classroom contained several hazards. Slightly above the floor a ventilation grate was loose as was the wire mesh attached to it. The metal wall mounted heating unit was covered in rust and loose peeling and bubbling paint. Both areas are accessible to children. Corrective Action: Repairs must be completed as soon as possible. Ensure children are supervised when they are using the bathroom. Send pictures to this licensor of the repairs by the corrective action due date. Moving forward ensure you are reporting hazardous conditions within the licensed space to the appropriate parties responsible for building up keep. Since the visit the Principal communicated via email that he would notifiy building maintenance and priortize repairs. If the school is unable to make the repairs by the corrective action due date please notify this licensor. Licensing action will not be taken if there is a delay in repairs. Status: Appeal Period.”

Correction date in the state record: Jan 13, 2026

Regulation 2.3.1.5: The licensee shall not interfere with, impede, deter, provide false information or cause another to do any of the aforementioned, or in any manner hinder the Department or its agent(s) in an investigation or inspection.

“On 12/18/2024 a violation was cited for regulation 7.3.2.4 because a trainee had not met assistant qualifications within a year of employment. This staff member will be refered to as Staff A on this report. The corrective action required that Staff A enroll in the Fundamentals training or one pursue one of the other qualification pathways. Corrective action required the director, [name], to contact [name] at Northern Lights at CCV to discuss qualification options for Staff A. On January 16th 2025, Amanda emailed this licensor and reported that the corrective action plan was to have Staff A complete Fundamentals,Staff A would complete the training on April 14th of 2025 at which time Amanda would send me a copy of the certificate and CC Joanne on the email.In April this licensor did not receive a Fundamentals certificate for Staff A. I contacted Joanne and she had no history of Staff A completing Fundamentals or contacting them about qualification requirements. In June Amanda was contacted by Licensing Supervisor [name] as the corrective action was now overdue and there was no evidence to support that Staff A met qualification requirements. In June Amanda told Supervisor Sheldrick that after the 12/18/2024 visit Staff A was only utilized as a substitute and therefore did not need to complete Fundamentals to meet assitant qualifications. Amanda then asked to remove Staff A from the program's associated parties list effective 06/18/2025 as they would no longer be working at the program. During this licensing visit I reviewed Dana's file and noted that Staff A continued to work at the program every Friday and sporadic hours during the rest of the week. This was the same schedule they held prior to the December 2024 licensing visit, a staff person with a set schedule is not considered a substitute. Amanda was asked to send emails that supported they reached out to Northern Lights in January of 2025 and provide evidence that Staff A was enrolled in Fundamentals as Amanda has stated in her 01/16/2025 email. Instead Amanda sent an email thread between Staff A and [name] that started on 09/15/2025 where Staff A stated they work at KPAS as an assitant but was told that they need to complete further qualification requirements. The thread captures that on October 7th Joanne had received and reviewed Staff A's transcripts and they actually met teacher associate qualifications which is higher than assistant qualifications and therefore Staff A did not need to complete Fundamentals. When Staff A was hired Amanda should have collected Staff A's transcripts and should have known that she did not need to complete additional coursework as Staff A already had over 21 college credits. This information further supports that [name] was never contacted in January of 2025 as required and Amanda's statement that Staff A was enrolling in Fundamentals was false. Additionally, Staff A was removed from the associated parties list because Amanda reported that Staff A no longer worked at the program. Emails between Staff A and [name] clearly indicate that Staff A continued employment after June 18th of 2025 when they were removed from the associated parties list. Amanda falsely reported Staff A was enrolling in Fundamentals, between January and April Amanda was aware that Staff A was not in Fundamentals but did not contact this licensor to report that information, Staff A did not contact Northern Lights until 10 months after the violation was cited and Amanda removed Staff A from the associated parties list on June 18th 2025 however in the emails from September of 2025 Staff A tells Joanne that she is an assistant at KPAS. Corrective Action: Moving forward the director will provide accurate information to licensing representatives. The director will communicate in a timely manner with licensing representatives and in the future may not alter position titles or employment end dates to avoid corrective action requirements. By the corrective action due date the director will email this licensor confirming that they have reviewed this violation and will ensure compliance with this regulation moving forward.Failure to complete corrective action requirements by the due date will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 3.4.1: The licensee shall keep all required records, schedules, materials, and equipment used to operate and maintain the CBCCPP in good order and in locations appropriate for day to day access.

“Records were not in good order or easy to quickly access. The director had to search in multiple places when I requested documents/records as noted in the violations on this report, many documents could not be located. Corrective Action: Work with the SPARQS Quality Support Specialist to create a system of storage in which documents/records required by licensing are organized and easy to access. At this time the corrective action is to submit an intake through SPARQS to request mentoring support. Contact this licensor when files are organized and ready for review. This licensor will conduct a follow up licensing visit and will inspect files. Failure to submit the intake with SPARQS by the corrective action due date will result in licensing action that places the program in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

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.

“There are no documents on site or in BFIS quality and credential accounts that reflect the director and one of the assistants have completed fifteen(15) hours of professional development. The director was provided with a deadline of 01/06/2026 to send professional development certificates to this licensor and failed to do so. Corrective Action: If the director and assistant have any trainings during their professional development year, which is based on start date at the program, submit those documents to Northern Lights at CCV and include this licensor by the corrective action due date. If the director and assistant have not completed fifteen(15) hours of professional development they are required to complete fifteen(15) hours by 02/01/2025. Failure to complete corrective action requirements will result in licensing action that will place the license in provisional status. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 3.4.5.1: A licensee shall maintain a complete and up-to-date personnel file for staff working at the CBCCPP. A complete file shall contain, at minimum, the following information: Name, date of birth, home address and telephone number; Copies of current first aid and CPR certification; Signed statement verifying understanding of legal requirement to report suspected child abuse and neglect; Documentation of a current Records Check Authorization form; Documentation of having read and having ready access to a current copy of applicable child care licensing regulations; Administration of Medication training certification (if applicable); Signed statement verifying current job title and supervisor's name; Application for employment including references or reference checks; Employment start date; Documentation of completed orientation Training; Employment end date; IPDP (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt); and Written annual performance reviews (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt).

“Seven(7) staff are employed at the program, each of those seven(7) files is incomplete. It was hard to locate the staff files and once the director found them she stated she may have some of the missing documents elsewhere or on her computer. Nonetheless, the files that were provided were each missing more than 50% of the required documentation listed in this regulation. This is a repeat violation that was cited on 12/20/2023. A talking point will be captured on this report that addresses the disorganization and difficulty in locating paperwork at the program. This is a repeat violation previously cited on 12/20/2023. Corrective Action: By the corrective action due date the director must submit an intake request with the SPARQS program requesting support from a Quality Support Specialist. The director will work with the Quality Support Specialist to develop a program improvement that will ensure staff files are complete moving forward. The director will communicate progress and notify me when all files are complete. Once files are complete this licensor will review the files on site. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 7.2.1: The licensee shall ensure that any new individuals regularly present at the CBCCPP submit a Records Check Authorization form to the Division prior to working with children in the CBCCPP.

“While on site I noticed an individual listed on the staff schedule, this individual was not listed on the program's BFIS associated parties list. This indicated that we had not processed a record check authorization form and the Child Development Division did not clear this person to work at the program. The director stated they sent the record check form, she was asked to forward the email in which she submitted the record check, she did not. I confirmed that we have no record of receiving a record check for that individual. After the visit the record check was submitted and the Child Development Division notified the program that this individual may work at the program but must complete fingerprinting. Federal and State statutes require that program submit record check authorization forms for all new staff prior to them working at the program.It should be noted that the record check indicated that they started employment at the program on 06/01/2024. Therefore they were included in the violations related to missing training documents as their BFIS account currently contains no training documents. This is a repeat violation cited on 12/20/2023. Corrective Action: By the corrective action due date schedule a fingerprinting appointment for this staff member and send a copy of the receipt to this licensor. They may not be left alone with children until the Child Development Division receives their fingerprint results and issues a clearance letter. This is a repeat violation and will require a program improvement plan. Work with the SPARQS Quality Support Specialist to create a system that will ensure you are submitting record check authorization forms for new staff and montitoring the program's BFIS account to ensure it is up to date and accurately reflects staff who are working at the program. At this time the only corrective action required is to enter an intake requesting mentoring supports from SPARQS. When the program improvement plan is complete email it to this licensor. Status: Appeal Period.”

Correction date in the state record: Jan 21, 2026

Regulation 7.3.2.4: "Trainee" A trainee is at least fifteen (15) years of age, able to comprehend basic written format, and meets one (1) of the following qualifications: 1) At least a high school graduate or has completed a GED and completes the Fundamentals for Early Childhood Professionals'course or the Vermont Afterschool Essentials Certificate within the first twelve (12) months of employment; or 2) At least a high school graduate or has completed a GED and successful completion of a three (3) college credit course in child or human development or in school age care and education within the first twelve (12) months of employment; or 3) At least is enrolled in or has received a State Board of Education approved Human Services Program Certificate that emphasizes child development or early childhood education.

“A violation for this regulation was cited on 12/18/2025. At the time of that visit Staff A had been employed as a trainee for more than one year and had not completed the additional qualification requirements. In January of 2025 [name], Program Administrator, told this licensor that Staff A was signed up for the Fundamentals early childhood course through Northern Lights at Community College of Vermont. Amanda stated that Staff A would be done with the course in April and once complete she would send the documentation to this licenor. Amanda did not submit the documents in April. This licensor contacted Northern Lights and they stated they have no record of Staff A signing up for the course or being on the waitlist for the course. On June 19th the program was issued a final overdue corrective action email. Amanda responded that Staff A was no longer working as a trainee and that she would remove her from the associated parties, however she also stated that the program uses Staff A as a substitute. Amanda was adivsed that she should not remove Staff A from the associated parties list if they are used as a substitute. Amanda did not respond to an email asking for the date Staff A switched from trainee to substitute nor did she respond to the question of why licensing was not notified in April that Staff A had not completed Fundamentals. At the time this report was generated Staff A is still reflected as a trainee. Corrective Action: By the new corrective action date the program will respond to the following questions. When did Staff A stop holding their postion of Trainee and why was licensing not made aware that Staff A did not sign up for Fundamentals after this licensor was told they had in January of 2025. Please send a copy of staff schedules that will support that Staff A was no longer working as a trainee. Failure to submit corrective action may result in a licensing visit and additional violations.”

Correction date in the state record: Jun 18, 2025

Regulation 7.3.2.4: "Trainee" A trainee is at least fifteen (15) years of age, able to comprehend basic written format, and meets one (1) of the following qualifications: 1) At least a high school graduate or has completed a GED and completes the Fundamentals for Early Childhood Professionals'course or the Vermont Afterschool Essentials Certificate within the first twelve (12) months of employment; or 2) At least a high school graduate or has completed a GED and successful completion of a three (3) college credit course in child or human development or in school age care and education within the first twelve (12) months of employment; or 3) At least is enrolled in or has received a State Board of Education approved Human Services Program Certificate that emphasizes child development or early childhood education.

“Staff B was hired as a Trainee on 08/20/2023 and was required within one year of employment to complete a path to assistant qualifications. Staff B did not complete the required qualification requirements within the first year of employment. Corrective Action: By the corrective action due please contact [name] at Northern Lights CCV and enroll Staff B in one of the qualification pathways bullet pointed in this regulation. The program will communicate with this licensor what pathway was chosen and the timeline for completion. Moving forward ensure that trainee's work towards meeting assistant qualifications within the first year of employment.”

Correction date in the state record: Jun 18, 2025

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

“Staff A's five(5) year fingerprint supported background clearance renewal was due by 05/18/2023. The Child Development Division did not receive a new record check authorization form and Staff A did not complete their five(5) year fingerprinting renewal. Corrective Action: Since the visit the program has submitted a new record check authorization form. Please have staff A schedule an appointment for fingerprinting. Please email a copy of that receipt by the due date. Please monitor staff fingerprint renewal dates and ensure the renewal process is started by submitting a new record check authorization form.”

Correction date in the state record: Mar 10, 2025

Regulation 7.1.2.2: Staff who are counted in the staff/child ratios and auxiliary staff left alone with children and/or counted in staff/child ratio as specified in the rule 6.2.1.8 of these regulations shall obtain training in pediatric first aid and in infant and child CPR within three (3) months of beginning work in the CBCCPP and remain currently certified.

“The Director's First Aid and CPR certification expired in December of 2022 and was not renewed. Corrective Action: Complete the First Aid and CPR training and submit documentation to Northern Lights @CCV and include this licensor on the email. If you have questions about which trainings are accepted please visit https://northernlightsccv.org.”

Correction date in the state record: Feb 8, 2024

Regulation 7.2.1: The licensee shall ensure that any new individuals regularly present at the CBCCPP submit a Records Check Authorization form to the Division prior to working with children in the CBCCPP.

“The Child Development Division has not received record check authorization forms for Staff A and Staff B. The Director stated she thought they had been sent. After the visit I confirmed that we have not received any record check authorization forms from this program. I asked that the Director resubmit the forms via email. The record check form contains the email where forms should be sent, the Director sent them to an incorrect address. This licensor then provided the Director with the correct email and once again asked that she submit the forms. The Director then stated that she snail mailed the forms and they should have arrived. On 01/04/2024 this licensor went to the Waterbury State Office complex and confirmed with the mail sorter that no mail as been received from this program. These forms should have been sent as soon as Staff A and B started and it is required that a copy of the record check authorization form is kept on site and that the program can provide proof that the form was sent. Furthermore it is the program's responsibility monitor their BFIS program account to ensure all staff are reflected on the associated parties list. Based on a search in BFIS Staff A and Staff B do not have BFIS credential accounts and therefore we have no background check information or qualification documentation for them. Corrective Action: Please email the record check forms directly to me. Please make sure that every section of the form is filled out and the start date reflects the first day they worked in the program with children. They may not be left alone with children until we have received fingerprint results. Please email me with the fingerprint appointment date(s) and provide written confirmation that you have reviewed this regulation and will create a system to ensure that record check authorization forms are submitted on or before a staff members first day working with children.”

Correction date in the state record: Jan 25, 2024

Regulation 3.4.5.1: A licensee shall maintain a complete and up-to-date personnel file for staff working at the CBCCPP. A complete file shall contain, at minimum, the following information: Name, date of birth, home address and telephone number; Copies of current first aid and CPR certification; Signed statement verifying understanding of legal requirement to report suspected child abuse and neglect; Documentation of a current Records Check Authorization form; Documentation of having read and having ready access to a current copy of applicable child care licensing regulations; Administration of Medication training certification (if applicable); Signed statement verifying current job title and supervisor's name; Application for employment including references or reference checks; Employment start date; Documentation of completed orientation Training; Employment end date; IPDP (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt); and Written annual performance reviews (Substitutes filling a staff position for less than thirty (30) consecutive days within a 365 day period shall be exempt).

“Staff A and B do not have complete staff files on site and record check authorization forms were not submitted so they do not have BFIS Quality and Credential accounts. Therefore there is no way to assess qualifications in order to determine what role they can have at the program. Additionally there were no records on site that Staff B completed FA/CPR, mandated reporter or Vermont Orientation. Corrective Action: Create staff files for Staff A and Staff B. Please send training and credential documents to Northern Lights at CCV and include this licensor. Once those documents are received I will be back in touch to discuss whether they qualify for their roles and what further steps may be needed. It is required that all staff have a file that is easily assessible and complete and remains on site.”

Correction date in the state record: Mar 27, 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.

“The program did not have documentation of monthly evacuation drills for 2023 there was no notation of an evacuation occuring during nap time. The program is housed in a public school but is a separately licensed and is responsible for conducting drills and documenting them. If the program participates in evacuation drills with the school, that is fine, as long as the program is documenting them in accordance with this regulation. This is a repeat violation from 5/15/2018 and 01/31/2022. Corrective Action: Plan to practice and record 2 evacuations a month for the next 3 months. This is is a repeat violation and is being cited for the third time. A program improvement plan is required. This plan shall contain the following: identify who will schedule and document evacuation drill logs, where the logs will be kept and what plans will be made to ensure that if an evacuation needs to be cancelled it is rescheduled. Please also let this licensor know when you plan to conduct an evacuation drill during rest time. The evacuation log will be inspected during the next visit if any of the corrective action pieces are not met this licensor may contact the Division of Fire Safety to report the repeated non compliance with fire safety regulations.”

Correction date in the state record: Jan 25, 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 was required to complete a fingerprint supported background check through the Child Development Division in August of 2022. Fingerprint results have not been received. Corrective Action: Plan to have Staff A schedule an appointment to complete fingerprinting. Staff A may not be left alone with children until the Child Development Division has received the fingerprint results. Email this licensor once Staff A has submitted to fingerprinting. Ensure moving forward that staff complete the fingerprint supported background check when they receive a notification to do so from the Child Development Division”

Correction date in the state record: Feb 1, 2023

Regulation 3.4.6.1: The licensee shall maintain a record of the date of each evacuation drill as required in the rules in section 3.7.2 of these regulations that includes the number of children and staff evacuated, time taken to evacuate, and notation of the drill conducted while children were sleeping or resting. Evacuation records shall be kept for two (2) years. When the CBCCPP counts lock-down drills as allowed in the rules in section 3.7.2 of these regulations, the licensee shall maintain a record of the date of each lock-down drill, the number of CBCCPP children and staff who participated, and note that the drill performed was a lock-down drill.

“Staff A was not immediately able to locate the evacution drill records. What was located indicated that evacuation drills were documented sporadically. The dates were written on slips of paper and indicated drills were practiced in November and December of 2020 and February and March of 2021. Corrective Action: Develop a system that ensures evacuation drills are practiced monthly and that the documentation includes all of the required information. Email a description of this system to this licensor.”

Correction date in the state record: Mar 14, 2022

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.

“The director does not have the required qualifications to run a program of this size that does not employ a business manager.There was a qualification variance in place for the director which expired on 09/02/2021, required coursework was not completed and the program did not notify licensing on or before the variance due date to report that they had not come back into compliance with this regulation. The expired variance also required that the director complete coursework to meet regulation 7.3.1.5 by the end of the Summer of 2022. This expectation is still in place. Corrective Action: The director must complete a three 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 3 college credit course in managing an early care and education program that includes budgeting and financial management. The program will be given 1 month to work with [name] at Northern Lights CCV and enroll the director in the required courses. The program also has the option to hire a qualified business manager if completion of the required coursework is not managable.”

Correction date in the state record: Mar 10, 2022

Regulation 5.1.4: The licensee shall submit a Vermont Child Care Immunization Report at least once every 365 days to the Vermont Department of Health, Immunization Office as required by 18 V.S.A. SS 1120 - 1129.

“Between 11/16/2021 and 12/17/2021, CDD sent two (2) separate emails to all programs, one (1) reminder letter using US Postal Service, one (1) reminder letter sent through the program's BFIS account, and a final email reminder. This communication provided the link to be used and CDD contact information for questions or challenges with submitting the report. The program did not submit their immunization report. Corrective Action: By 02/23/2022, reflect on why the report was not submitted in a timely manner for 2021, and submit an email that identifies what happened with the 2021 report and what steps will be taken to ensure that the 2022 annual immunization report will be filed between 11/1/2022 - 12/31/2022.”

Correction date in the state record: Mar 14, 2022

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 Quality and Credentialing Accounts and staff file reflected that the 3 staff members had not yet completed an Orientation Training. Corrective Action: Immiately plan to have all staff complete an approved Orientation Training. A link to the online VT Orientation training can be found on the Child Development Division Website, go to dcf.vermont.gov, then follow prompts for Our Divisions, Childcare for Providers, Professional Development, Required Trainings. Develop a system which will prompt staff to complete an approved orientation training in a timely manner and prior to being left alone with children moving forward.”

Correction date in the state record: Apr 3, 2020

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 Quality and Credentialing accounts and staff files reflected that the staff had not yet completed the required mandated reporter training. Corrective Action: Immediately plan for all staff to complete the online mandated reporter training, Protecting Vermont's Children. You can access the training by going to the Child Development Division website, DCF.vermont.gov, then follow the prompts for; Our Divisions, Childcare for Providers, Professional Development, Required Trainings. Develop a system to ensure that all staff complete the required mandated reporter training in a timely manner moving forward.”

Correction date in the state record: Apr 3, 2020

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 Quality and Credentialing Accounts reflected that staff A, B, and C had not submitted documentation of completing Mandated Reporter training, an approved Orientation Training, verification of qualifications, and current CPR and first aid certificates. Corrective Action: Immediately plan to have all staff submit all required documents with cover pages to Northern Lights at CCV(NLCCV). If you need assistance with submitting documents to NLCCV, you may reach out to your NLCCV resource adivisor, [name], at (802) 828-0621 or joanne.rouleau01@ccv.edu. Develop a system which will prompt all staff members to submit all required documents to NLCCV in a timely manner moving forward.”

Correction date in the state record: Apr 3, 2020

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

“The director stated that some children bring lunchboxes with food from home that often includes perishable items and that these lunchboxes contain ice packs rather than being stored in a refrigerator. Corrective Action: Immediately plan to store all perishable foods in the refrigerator.”

Correction date in the state record: Mar 24, 2020

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.

“Since September 2017, the program has been alternating between types of drills practiced each month and has not been practicing monthly emergency evacuation drills. Corrective Action: The children and staff shall practice emergency evacuation drills each month and during this visit the program director agreed to do so.”

Correction date in the state record: May 15, 2018