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August 18, 2023 CERTIFIED MAIL Fay Hopkins, Authorized Agent The Legacy of Dr. Josie R. Johnson Montessori School 5140 Fremont Ave N Minneapolis, MN 55430-3419 License Number: 1027351 (Child Care Center) ORDER OF CONDITIONAL LICENSE Dear Fay Hopkins: The Department of Human Services (DHS) is placing your license to provide child care services at The Legacy of Dr. Josie R Johnson Montessori School, located at 5140 Fremont Ave N, Minneapolis, MN 55430-3419, on conditional status for two years. Because your license is currently not operating, the conditional license will go into effective the day your program re-opens. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with child care center licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On May 31, 2023, a DHS licensor conducted a licensing review at your facility located at 5140 Fremont Ave N, Minneapolis, MN 55430-3419. As a result of this licensing visit, the DHS licensor determined that your program failed to comply with the laws and rules that apply to licensed Child Care Centers, citing 26 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of children by the program. Nature and Severity: On May 31, 2023, a DHS licensor determined 26 licensing violations. Sixteen of the 26 violations are repeat violations for which you were previously cited. Numerous violations related to the health and safety of children, including:
o Failure to comply with background study requirements (addressed in a separate Order to Pay a Fine on July 21, 2023) o Failure to maintain staff distribution requirements o Failure to operate within the terms of your license o Failure to keep hazardous items away from children o Failure to comply with staff training requirements, including orientation, CPR, first aid, annual in-service, abusive head trauma, and child development and learning o Failure to supervise children Chronicity: On May 31, 2023, a DHS licensor determined 26 licensing violations. Sixteen of the 26 violations are repeat violations for which you were previously cited. Your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o August 2, 2023 Conditional License (this order 26 violations (16 repeat) o July 24, 2023 Order to Pay a Fine 4 Background Study Violations o April 18, 2022 Correction Order 17 violations (7 repeat) o August 16, 2021 Correction Order 4 violations (4 repeat) o May 2, 2019 Correction Order 14 violations (2 repeat) o June 7, 2019 Order to Pay a Fine 4 Background Study Violations o February 13, 2019 Correction Order 9 violations (2 repeat) o March 27, 2019 Order to Pay a Fine 1 Background Study Violation Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of children in your care, your license to provide child care is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. PROGRAM PRACTICES 1. Violation: Staff distribution requirements were not maintained. A teacher or assistant teacher did not directly supervise an aide. · Three aide qualified staff persons were supervising 15 children. A teacher qualified staff person was required. (Preschool 102: Preschool/School age classroom) · Two aide qualified staff persons were supervising six children. A teacher qualified staff person was required. (Sumos Uno Community 214: Toddler classroom) · Two aide qualified staff persons were supervising 13 children. A teacher qualified staff person was required. (Kinders 101: Preschool/School age classroom) Rule Violated: Minnesota Rules, part 9503.0034, subpart 1; and part 9503.0040, subpart 2, item D 2. Violation: The program was not operating within the terms of the license. · The preschool children were in a room that was not approved as licensed space. · Through a conversation with an administrative staff person, it was determined that on more than one occasion children were in the family and sensory rooms, which are not approved as licensed spaces. (Facility) Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (a) 3. Violation: Staff did not supervise the children at all times. · A preschool child was in the hallway at the lockers unsupervised for a few minutes. (Preschool 102: Preschool/School age classroom) · While all of the children were in one half of the classroom, one child came over to the other half where the DHS licensor was. For several minutes during this time a staff person could not see the child, and it appeared that staff were unaware that the child had left the group. (Preschool 102: Preschool/School age classroom) Supervision occurs when a program staff person is accountable for the child's care and is within sight and hearing of a child at all times, so that the program staff person can intervene to protect the health and safety of the child. Statute Violated: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated February 13, 2019. FOOD AND WATER 4. Violation: Meals did not comply with the nutritional requirement of the USDA. The children were not served milk at lunch. (Preschool 102: Preschool/School age classroom) Rule Violated: Minnesota Rules, part 9503.0145, subpart 4 5. Violation: Menus did not comply with the nutritional requirements of the USDA. Menus did not include: · fluid milk; · a meat or meat alternate; · a fruit; · a vegetable; and · a grain. Rule Violated: Minnesota Rules, part 9503.0145, subpart 2 Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. 6. Violation: Water bottles were used to provide drinking water to children and the program did not follow the policy for cleaning and sanitizing water bottles. Children were using water bottles that were not labeled with their first and last names. (Preschool 102: Preschool/SA classroom and Kinders 101: Preschool/SA classroom) Statute Violated: Minnesota Statutes, section 245A.14, subdivision 17 MEDICATION/FIRST AID 7. Violation: The record of medication administration form did not include the name and signature of the person dispensing the medication. Rule Violated: Minnesota Rules, part 9503.0140, subpart 7, item C FACILITY 8. Violation: The program did not comply with cleanliness requirements; the indoor space was not clean. · The carpet had several visible dirty spots. (Preschool 102: Preschool/SA classroom) · There was one unflushed toilet in the women's bathroom. (Facility) As defined in Minnesota Rules, part 9503.0005, subpart 9, clean means 'free from dirt or other contaminants that can be detected by sight, smell, or touch. Rule Violated: Minnesota Rules, part 9503.0140, subpart 9 9. Violation: Children did not have access to facial tissue in the Sumos Uno Community 214, Kinders 101, and the After Care 103 classrooms. Rule Violated: Minnesota Rules, part 9503.0140, subpart 15 10. Violation: Children did not have access to hand towels in the men’s bathroom. (Facility) Rule violated: Minnesota Rules, part 9503.0140, subpart 15 11. Violation: The DHS licensor observed that hazardous objects were accessible to children. · Two staff purses were accessible to children. (Preschool 102: Preschool/SA classroom) · There were many sharp thistles on the preschool playground that were accessible to children. · There was a slide and three swings on grass on the preschool playground. · There was a dome climber and two slides were on grass on the toddler playground. Grass is not considered an adequate surface under and around large muscle equipment to protect children from injury. (Facility) Rule and Statute Violated: Minnesota Statutes, section 245A.66, subdivision 2, paragraph (e) and Minnesota Rules, part 9503.0140, subpart 17 Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated February 13, 2019 · A Correction Order dated April 18, 2022 · A Correction Order dated August 16, 2021 12. Violation: Areas used by the children were not in good repair.
Part of the rubber floor baseboard had peeled off the wall, exposing drywall. (Preschool 102: Preschool/SA classroom) Rule Violated: Minnesota Rules, part 9503.0140, subpart 20 13. Violation: A rug or rugs were not free from tears and were curled or had frayed edges. The carpet had a tear and a frayed edge with a string approximately one foot long. (Preschool 102) Rule Violated: Minnesota Rules, part 9503.0140, subpart 20 14. Violation: Electrical outlets were not tamper-proof or shielded. · One outlet on the wall and three outlets on a power strip were not tamper-proof or shielded. (Preschool 102: Preschool/School age classroom) · Four electrical outlets were not tamper-proof or shielded. (After Care 103: Preschool classroom) Rule Violated: Minnesota Rules, part 9503.0155, subpart 1 Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated May 2, 2019. STAFF QUALIFICATIONS 15. Violation: The program did not have documentation on site to show that 1 of 1 (SP4) staff persons met the experience requirements of the teacher job classification for which the staff person was employed (SP4). Rule Violated: Minnesota Rules, part 9503.0032, subpart 2; and part 9503.0120, item B Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated May 2, 2019 · A Correction Order dated April 18, 2022 STAFF TRAINING 16. Violation: Documentation was not available on site to verify that before starting assigned duties 4 of 4 (SP4, SP7, SP8 and SP9) individuals (director, staff persons, substitutes, or unsupervised volunteers) received orientation training on: · the risk of abusive head trauma that was at least one-half hour in length as required under subdivision 5a (SP4, SP7, SP8 and SP9); · allergy prevention and response as required by Minnesota Statutes, 245A.41, subdivision 1 (SP4, SP7, SP8 and SP9); · behavior guidance policy standards in Minnesota Rules, part 9503.0055 (SP4, SP7, SP8 and SP9); · the child care program plan and center's philosophy (SP4, SP7, SP8 and SP9); · emergency preparedness as required by Minnesota Statutes, 245A.41, subdivision 3. (SP4, SP7, SP8 and SP9); · handling and disposal of bodily fluids as required by Minnesota Statutes, 245A.41, subdivision 2 (SP4, SP7, SP8 and SP9); · handling emergencies and accidents according to Minnesota rules, part 9503.0110 (SP4, SP7, SP8 and SP9); · procedures for maintaining health and safety according to Minnesota Rules, part 9503.0140 (SP4, SP7, SP8 and SP9); · a child's individual child care program plan as required under Minnesota Rules, part 9503.0065, subpart 3 (SP4); · specific job responsibilities (SP4, SP7, SP8 and SP9); · program's drug and alcohol policy under section 245A.04, subdivision 1, paragraph (c) (SP4, SP7, SP8 and SP9); · reporting responsibilities in Minnesota Statutes, chapter 260E (MOMA) and 9503.0130 (SP4, SP7, SP8 and SP9); · program's risk reduction plan as required under section 245A.66, subdivision 2 (SP4, SP7, SP8 and SP9); and · sudden unexpected infant death that was at least one-half hour in length as required in subdivision 5 (SP4). Statute Violated: Minnesota Statutes, section 245A.40, subdivision 1; and section 245A.04, subdivision 14, paragraph (b), clause (1) Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated February 13, 2019 · A Correction Order dated May 2, 2019 · A Correction Order dated August 16, 2021 · A Correction Order dated April 18, 2022 17. Violation: The required in-service training had not been completed for 5 of 5 (SP3, SP4, SP5, SP6 and SP7) individuals (director, staff persons, substitutes, or unsupervised volunteers) for the previous concluded calendar year 2022. In-service training did not include: · the required number of in-service training hours for the previous concluded calendar year (SP3, SP4, SP6 and SP7); · training on abusive head trauma that was at least one-half hour in length as required by Minnesota Statutes, section 245A.40, subdivision 5a (SP3, SP4 and SP6); · training on allergy prevention and response as required by Minnesota Statutes, section 245A.41, subdivision 1 (SP3, SP4 and SP6); · training on emergency preparedness as required by Minnesota Statutes, section 245A.41, subdivision 3 (SP3, SP4 and SP6); · training on handling and disposal of bodily fluids as required by Minnesota Statutes, section 245A.41, subdivision 2 (SP3, SP4 and SP6); · training on handling emergencies and accidents as required by Minnesota Rules, part 9503.0110, subpart 1 (SP3, SP4 and SP6); · training on health policies as required by Minnesota Rules, part 9503.0140, subpart 1 (SP3, SP4 and SP6); · training on reporting responsibilities as required by Minnesota Statutes, chapter 260E and Minnesota Rules, part 9503.0130 (SP3, SP4 and SP6); · training on the risk reduction plan as required by Minnesota Statutes, section 245A.66, subdivision 2 (SP3, SP4 and SP6); · training on cultural dynamics every two years as required by Minnesota Statutes, section 245A.40, subdivision 7 (4) (SP5 and SP6); and · training on disabilities every two years as required by Minnesota Statutes, section 245A.40, subdivision 7 (5) (SP3, SP5 and SP6). Statute Violated: Minnesota Statutes, section 245A.40, subdivision 7 Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated May 2, 2019 · A Correction Order dated April 18, 2022 18. Violation: The program did not comply with abusive head trauma training requirements. The training on abusive head trauma for 7 of 7 (SP3, SP4, SP5, SP6, SP7, SP8 and SP9) individuals (director, staff persons, substitutes, or unsupervised volunteers) was not completed before caring for children under school age. Statute Violated: Minnesota Statutes, section 245A.40, subdivision 5a, paragraph (a)
Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. 19. Violation: The program did not comply with cardiopulmonary resuscitation (CPR) training requirements. Documentation was not available on site to show that 5 of 6 (SP3, SP5, SP6, SP7 and SP9) individuals (director, staff persons, substitutes, or unsupervised volunteers) had satisfactorily completed the required pediatric CPR training including the treatment of obstructed airways and a hands-on skill assessment: · within 90 days of the start of work or within the previous two years (SP5, SP7 and SP9); · within the previous two years (SP3 and SP6); and · before unsupervised contact with a child (SP5). Statute and Rule Violated: Minnesota Statutes, section 245A.40, subdivision 4 and Minnesota Rules, part 9503.0120, subpart D Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated May 2, 2019 · A Correction Order dated April 18, 2022 20. Violation: The program did not comply with first aid training requirements. Documentation was not available on site to show that 5 of 6 (SP3, SP5, SP6, SP7 and SP9) individuals (director, staff persons, substitutes, or unsupervised volunteers) completed pediatric first aid training: · within 90 days of the start of work or within the previous two years (SP7 and SP9); · within the previous two years (SP3, SP5 and SP6); and · before unsupervised direct contact with a child (SP5). Statute and Rule Violated: Minnesota Statutes, section 245A.40, subdivision 3 and Minnesota Rules, part 9503.0120, subpart D Repeat Violation: The license holder was cited for a similar violation in the following orders: · A Correction Order dated May 2, 2019 · A Correction Order dated April 18, 2022 21. Violation: The program did not comply with child development and learning training requirements. Documentation was not available on site to show that 5 of 6 (SP3, SP5, SP6, SP7 and SP9) individuals (director, staff persons, substitutes, or unsupervised volunteers) completed training at least every second calendar year (SP3, SP5 and SP6); and completed training within 90 days of employment (SP7 and SP9). Statute Violated: Minnesota Statutes, section 245A.40, subdivision 2 Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. CHILDREN’S RECORDS 22. Violation: Each child's record did not contain all required information: · 2 of 2 (C1 and C5) children's files reviewed did not contain the child's full name, birth date, and current home address; · 2 of 2 (C1 and C5) children's files reviewed did not contain the name, current home address, and telephone number of both parents and/or legal guardians; · 2 of 2 (C1 and C5) children's files reviewed did not contain instructions on how the parent and/or legal guardian can be reached when the child is at the center; · 3 of 5 (C1, C2 and C5) children's files reviewed did not contain the names and telephone numbers of anyone authorized to take the child from the program; · 2 of 2 (C1 and C5) children's files reviewed did not contain the names, addresses, and telephone numbers of the child's source of regular medical and dental care and source of emergency medical and dental care; · 5 of 5 (C1, C2, C3, C4 and C5) children's files reviewed did not contain the names, addresses, and telephone numbers of two persons to be contacted if a parent cannot be reached in an emergency or when there is an injury requiring medical attention; · 2 of 2 (C1 and C5) children's files reviewed did not contain written authorization for the center to act in an emergency or when the parent cannot be reached or is delayed; and · 2 of 2 (C1 and C5) children's files reviewed did not contain the hours and days of the week the child will attend the program. Rule Violated: Minnesota Rules, part 9503.0125 Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. 23. Violation: Two of two (C1 and C5) children's files reviewed did not contain documentation of a current physical examination received within 30 days of enrollment. Rule Violated: Minnesota Rules, part 9503.0125, item G; and part 9503.0140, subpart 3 24. Violation: Two of five (C1 and C5) children's files reviewed did not contain a current immunization record, a signed notarized statement of parental objection to the immunization, or a medical exemption. Rule Violated: Minnesota Rules, part 9503.0125, item G; and part 9503.0140, subpart 5 Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated May 2, 2019. EMERGENCY PREPAREDNESS 25. Violation: The program did not comply with the Child Care Emergency Preparedness Plan. The program did not have a written emergency plan for emergencies that requires evacuation, sheltering, or other protection of a child, such as fire, natural disaster, intruder, or other threatening situation that may pose a health or safety hazard to a child. Rule Violated: Minnesota Statutes, section 245A.41, subdivision 3, paragraph (a) Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. 26. Violation: The relocation site and evacuation route was not posted in a visible place as a part of the written procedures for emergencies and accidents in Minnesota Rules, part 9503.0140, subpart 21. Statute Violated: Minnesota Statutes, section 245A.41, subdivision 3, paragraph (f) Repeat Violation: The license holder was cited for a similar violation in a Correction Order dated April 18, 2022. Immediate corrective action required You must immediately correct the violations cited above. Submit documentation to your licensor within 30 days from when you received this order explaining how you have corrected the violations. If you fail to demonstrate substantial compliance with child care center requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. Additionally, DHS will not approve a request to increase your childcare services from the date of this order until the time your conditional license expires. CONDITIONAL LICENSE TERMS In addition to the child care center licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from receipt of this order, you must provide written notification of the conditional status of your license to all parents/legal guardians. Prior to providing the written notification to all parents/legal guardians, you must submit the written notice to your DHS licensor for approval. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. 2. On an ongoing basis while your license is on a conditional status, you must maintain a list of all newly hired employees who will have direct contact with children served by the program. The documentation required under this term must be maintained onsite and made immediately available to DHS upon request. For each individual on the list, you must document the following: · the individual’s full name; · the individual’s job title; · the date of hire; · the date the individual first had direct contact with children served by the program; and · the date the background study request was submitted to DHS. 3. On a monthly basis while your license is on conditional status, you must complete staffing patterns that identify every staff person and his/her job title included in the staff-to-child ratio for each classroom and maintain all completed staffing patterns onsite. The staffing information must be documented on the form titled “Staffing Patterns,” must be completed separately for each classroom, and must include the total number of children in attendance each hour for each classroom. The documentation must include the time each person takes their break, if applicable, and identify the name of the person who replaces them. Staffing patterns must be completed at the beginning of each month and made immediately available to the Commissioner upon request. Within 30 days from the receipt of this order, you must develop a plan to ensure staff to-child-ratios are maintained at all times and submit the plan to your licensor for approval. 4. Within 45 days from receipt of this order, you must ensure that all staff persons have successfully completed training as required under Minnesota Statutes, section 245A.40, as well as training on your risk reduction plan as required under Minnesota Statutes, section 245A.66, subdivision 3. You also must ensure that new hires successfully complete all applicable training. You must maintain documentation of the completed training in each staff person’s personnel record. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Even though your center is not in operation, you must comply with the timelines below. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision and run for two years from that date. You continue to be required to comply with all child care center laws and rules. Posting of this licensing action You are required to place this Order of Conditional License in a place that is clearly noticeable to the people receiving services and all visitors to the facility for two years, even if you request reconsideration. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Child care centers are required to follow Minnesota Rules, parts 9503.0005 to 9503.0170; and Minnesota Statutes, Chapters 245A, 245C, and 260E. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · The requirement to post this order in a clearly visible location is required under Minnesota Statutes, section 245A.06, subdivision 8. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Donna Gainor, Supervisor, at 651-431-6529. Sincerely,
Peggy Cunningham, Unit Manager Licensing Division Office of Inspector General
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