Incident investigation·May 16, 2025

On Friday, May 16, 2025 Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced Case Management inspection to follow-up on an Unusual Incident Report (UIR) submitted to Community Care Licensing CCL on April 30, 2025. LPA met with Director Kelli Murphy, Staff 2 (S2) and conducted a tour of the facility. LPA interviewed the director and staff member during this inspection. On April 30, 2025, CCL received information via UIR that on April 14, 2025, during nap time, Child One (C1) began throwing a tantrum, kicking, and punching a teacher, Staff One (S1). As a result of C1's behavior, S1 carried C1 to the restroom, and held the "Pony Door" shut with C1 inside the restroom with the attempt to allow C1 to calm down. Interview with S1 confirmed the statement provided, and S1 further stated that C1 did in fact calm down, eventually. According to S1, this was common practice for C1's behaviors at least once weekly. In addition, the incident was not reported to CCL in a timely manner. Record review confirmed that the CCC was operating within proper staff to child ratios at the time of incident. S2 relayed that the expectation for staff experiencing this kind of challenge would be to let management know in a timely manner so that there can be proper intervention of a child's behavior. S2 admitted this did not happen on the day of incident. S2 relayed the facility has been continuing advanced crisis training for staff so that staff can feel more confident when presented with challenging behaviors from children. Based on information gathered, the CCC did not act appropriately and a violation of Title 22 was found. An exit interview was held with Program Director Cheryl Hughes, and Director Kelli Murphy. A copy of this report was issued, along with copies of the LIC809-D (deficiency page), LIC811 (confidential names list), Appeal Rights, and a Notice of Site visit. This report shall be public record for three years. The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00. If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days, and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.