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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1088047-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV1) was without staff person knowledge or supervision for undetermined amounts of time on four separate occasions including: · One time AV1 was found in a parking lot; · One time AV1 was found in a school hallway by a student and brought back to the facility; · One time AV1 was found in a community pool area by a staff person (P2); and · One time AV1 was found in a toddler classroom. Allegation Two: During the course of this investigation, it was reported that two alleged victims (AV2 and AV3) were on one side of a partitioned gymnasium (gym) without staff person knowledge or supervision for approximately four minutes. Date of Incident(s): Allegation One: Multiple dates, some unknown, prior to March 22, 2024 Allegation Two: February 1, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 29, 2024; from documentation at the facility; and through seven interviews conducted with one supervisory staff person (P1), four facility staff persons (SP1, SP2, SP4, and P2), AV2’s family member (FM2), and AV3’s family member (FM3). (Note: SP2 was AV1’s family member). This investigator also reached out to an additional staff person (SP3) by telephone and mail to request an interview, but SP3 did not respond. This investigator also reached out to AV1’s family member (FM1), but s/he did not provide any information to this investigator. AV1 was between 29 and 39 months old at the time of the incidents and was enrolled in the Toddler classroom and then the Preschool classroom. AV2 was 23 months old and AV3 was 22 months old, and they were both enrolled in the Toddler classroom at the time of the incident in February 2024. The facility was located in a community building which also housed an elementary school. The main entrance to the community building entered into a front lobby with a view into the pool area through floor to ceiling glass windows. There was a front desk in the front lobby that was staffed by a community building staff person. There was a hallway that led to the facility classrooms. Along one side of the hallway was the gym and on the other side of the hallway there were offices for the facility. There was another entrance door at the end of this hallway that was the primary door used by children and their family members. This door led outside to an unfenced outdoor play area used by the facility, and to the parking lot. The toddler classroom was adjacent to the preschool classroom. A half wall separated the preschool bathroom from the preschool classroom. This allowed staff persons to be able to see over the wall and into the bathroom while allowing children privacy. The bathroom was open from the preschool classroom to allow children access to use the bathroom and wash their hands, and on the other side of the bathroom was a doorway with a half door which led to the toddler classroom. The pool area was connected to the facility classrooms by a series of hallways. The door to the pool area was locked at all times when a lifeguard was not on duty. The facility’s Keeping Youth Safe policy stated that staff persons were expected to keep the children in their care within sight and sound at all times. The facility’s Risk Reduction Plan stated, “Children are supervised at all times while using the play area. When the children are walking from the building to the play area, staff [persons] are watching them closely at all times to ensure their safety. Children are supervised when they use the toilet and wash their hands. Staff [persons] will supervise all areas by doors, especially exits. A Red Cross certified lifeguard will be on duty at all times that the children are swimming. When times (sic) that a lifeguard is not on duty, the pool area is locked.” Facility records showed that P1, P2, SP1, SP2, SP3, and SP4 each received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states that a child must have supervision at all times and that supervision is defined as occurring when a program staff person 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.
Allegation One: P1 stated that AV1 “sometimes” let go of the loops on the walking rope (a rope with loops attached that children hold while walking with a group) and ran off, but P1 had no concerns that staff persons were not supervising AV1. P1 was not aware of any other supervision issues regarding AV1. P2 stepped into the classrooms intermittently if a staff person needed a break or to help with a transition, anywhere from 15 to 60 minutes. P2 was not always involved when incidents happened due to his/her position with the facility, but P2 did not know of any supervision issues when staff persons were unaware that a child had left. P2 did not have concerns about supervision with staff persons. SP4 stated that AV1 “just dart[ed]” when s/he wanted to find SP2. SP4 said it had become a regular conversation with SP2 and that SP2 felt staff persons were “targeting” AV1, but the staff persons were just telling SP2 that AV1 ran away from the staff persons. SP1 stated that AV1 liked to run away from the group. AV1 tried to “dart” when the classroom was transitioning to the gym or tried to “dart” into the hallway from the classroom. When that happened staff persons shouted out AV1’s name and staff persons who were in the offices would help stop AV1 and bring him/her back to the group. Regarding AV1 in a parking lot: SP2 stated that on an unknown date in summer 2023, s/he was told about a week after the incident occurred, that SP1 saw AV1 in the parking lot and then SP1 showed SP2 where AV1 was found by the street parking spots. SP1 told SP2 that AV1 got out and made it seem like it “was not a big deal” that AV1 was in the parking lot. SP2 stated s/he received no other information about how AV1 got out of the building, who else was involved, or when the incident occurred. SP1 stated that on an unknown date in summer 2023, s/he was working in the toddler classroom and the class was using the outdoor space, including AV1. While the group was transitioning to a walkway by holding hands, AV1 broke free from another child’s hand and ran toward the parking lot. SP1 screamed and grabbed AV1 “immediately.” SP1 notified SP2 right away. SP4 was not aware of any incident in the parking lot. The facility’s Internal Review stated that on an unknown date in summer 2023, SP1 was working in the toddler classroom. SP1 was getting the children ready to go outside, including AV1 when AV1 pushed open an exterior door and bolted outside. SP1 saw this, ran after AV1, and caught up with AV1 a few steps outside of the exterior door. SP1 returned AV1 safely to the group and continued to get the group ready to go outside. Regarding AV1 in the school hallway: SP2 stated that on an unknown date, AV1 left the classroom, wandered into the school part of the community building and was found by a student. SP2 shared no other information about this incident. SP1 stated that on an unknown date in September 2023, SP1 was walking with a group of children, including AV1, in the hallway of the school part of the community building, and AV1 ran away from the group, but was in sight of SP1 at all times. SP1 stated that the school was not in session at that time and there were no classes going on in that hallway. Regarding AV1 in the community pool area: The facility’s Parent Handbook stated, “The [facility’s] pools are staffed by trained lifeguards at all times and children wear lifejackets during their entire visit. Children will be kept in sight at all times.” SP2 stated that on January 16, 2024, s/he was told by SP3 that after the preschool classroom returned from swimming, AV1 ran down the hallway, was found in the pool area alone, and was brought back to the classroom by P2. SP2 stated s/he did not know if the doors to the pool area were locked. SP2 stated that there were lifeguards, but no one was in there at that time of the incident because someone would have noticed AV1 right away. P2 stated that on an unknown date, P2 was alerted by SP1 that a child (P2 was not able to recall the name of the child) ran out of the facility area and into the community building. P2 assisted in finding the child in a hallway. P2 stated s/he did not find any child in the pool area. The facility’s Internal Review stated that on an unknown date, SP3 was working with a group of children including AV1 when AV1 and another child “bolted” away from the group, ran down the hallway, and around the corner. SP3 verbally tried to stop them, and then hurried the remaining children with SP3 to catch up to the other two children. When SP3 caught up with them, they were near the locked door of the pool area near the back exit. SP3 was able to redirect them and got the whole group back to the classroom. SP3 said the children were out of sight for “less than a few seconds” after they turned the corner. SP1 stated that s/he was not at the facility on the day of the incident, but heard that AV1 ran out of the gym, and P2 “immediately” went after AV1 and found him/her in the back hallway. Later, when SP1 spoke with AV1’s family member (FM1) about the incident, FM1 was under the impression that AV1 had gotten into the pool area and was alone. SP1 stated the pool doors remained locked when there was not a lifeguard on duty and the pool was closed when the incident occurred. SP4 said it was “impossible” for AV1 to be in the pool area alone because the pool doors were locked when there was no lifeguard on duty. SP4 said when the preschool classroom went to the pool there was a lifeguard on duty and two staff persons present, and when the preschool classroom left the pool at 10:45 a.m., the lifeguard closed the pool from 10:45-11 a.m. for a safety break. SP4 heard FM1 say that AV1 was found in the pool area alone before and SP4 thought that referenced when AV1 ran away from the group and was found in the hallway that looked into the pool through a glass window. P1 knew “absolutely nothing” about AV1 being left alone in the pool area and felt someone would have let him/her know. P1 stated there was always a community building staff person at the front desk, anytime the pool was open there was a lifeguard on duty, and the doors to the pool were locked when the lifeguard was not on duty. Regarding AV1 in the toddler classroom: SP2 stated that sometime in March 2024, SP1 told SP2 that AV1 went from the preschool classroom to the toddler classroom and was found in the toddler classroom alone by SP1. SP1 told SP2 that the doors to the classrooms need to be locked because AV1 was getting out of the classroom. SP2 stated that both doors continued to be propped and not shut all of the way, and AV1 was able to push the doors open. SP2 stated s/he did not know how long AV1 was alone in the toddler classroom. SP4 stated that on an unknown date in March 2024, SP1 and SP4 were in the preschool classroom with AV1. AV1 “always” wanted to be in the toddler classroom where SP2 worked, and on that day, AV1 ran though the bathroom into the toddler classroom. SP1 followed right away. SP1 stated on an unknown date in February 2024, AV1 was in the bathroom and SP1 noticed AV1 was not washing his/her hands. AV1 had gone through the bathroom into the toddler classroom and SP1 went in there to find the AV. SP1 reviewed video footage and said it was about five seconds that AV1 was in the toddler classroom alone. SP1 said the bathroom was an open space with “semi privacy.” Staff persons were able to see in there over the wall. After the incident a baby gate was put up to stop children from going to from the bathroom to the toddler classroom. The facility’s Internal Review stated that on March 16, 2024, SP1 and SP4 were in the preschool classroom getting ready to change shifts, so they were exchanging information about the children’s day so far. At that time, AV1 entered the bathroom to use the bathroom. As SP1 and SP4 continued talking they realized AV1 was no longer visible in the bathroom and went through the bathroom to the toddler classroom where the found AV1 alone. AV1 was brought back into the preschool classroom, and SP1 and SP4 thought the whole incident was under one minute.
This investigator was not able to review video footage. Conclusion Allegation One: Regarding AV1 in a parking lot and regarding AV1 in the school hallway: SP2 said s/he was told by SP1 that AV1 was found in the parking lot, but SP1 did not provide more information to SP2. SP1 stated that s/he was outside with a group of children including AV1 when AV1 ran toward the parking lot. SP1 screamed and intervened right away. On another occasion SP2 said s/he was told that AV1 was found in the school part of the community building and returned by a student. SP2 shared no other information about this incident. SP1 stated that sometime in September 2023, when the school was on break and there were no classes taking place in classrooms in the school hallway, AV1 ran down the hallway away from SP1 and the rest of the class, however AV1 was never out of sight of SP1. Although SP2 stated AV1 was found in the parking lot and in the school hallway, given that SP1 stated AV1 ran away from the group and was within sight of SP1 each time; without further information to support or refute these allegations, there was not a preponderance of the evidence that AV1 was without supervision. Regarding AV1 in the community pool area: SP2 heard from SP3 that on January 16, 2024, after returning from swimming, AV1 ran away from the group and was found in the pool area alone by P2. SP4 heard FM1 repeat that same version of events, but said that scenario was “impossible” because the doors to the pool area were locked when a lifeguard was not on duty. P2 stated that on an unspecified date s/he assisted in returning a child to the classroom who had run off, but P2 did not recall who the child was. P2 denied finding any child in the pool area unsupervised. In the Internal Review, SP3 stated that s/he saw two children including AV1 ran away from SP3 while they were in the hallway and SP3 caught up to them near the door to the pool area, but that AV1 and the other child were only out of sight for a few seconds after they turned the corner. Information from all sources was consistent that when the preschool children went swimming, there were always two staff persons and a lifeguard in the pool area. When the preschool children left the pool area, the lifeguard did a safety check and locked the doors for his/her break. The pool was visible from the main lobby of the community building and there was a community building staff person at the front desk at all times. Although SP2 stated s/he was told that AV1 was found in the pool area alone by P2, given that P2 stated s/he did not find a child in the pool area, that SP3 stated that on one occasion AV1 and another child ran away from him/her and were found near the door to the pool area seconds later, and that there were safety measures in place that made it unlikely AV1 would be able access the pool alone, there was not a preponderance of the evidence that AV1 was in the pool area without supervision. Regarding AV1 in the toddler classroom: SP2 heard from SP1 that AV1 went from the preschool classroom to the toddler classroom and was found alone in the toddler classroom by SP1. SP1 and SP4 provided information that they were in the preschool classroom with AV1 and AV1 used the bathroom then entered the toddler classroom through the bathroom. SP1 followed after AV1 and returned him/her to the preschool classroom. SP1 reviewed video footage and AV1 was alone in the toddler classroom for approximately five seconds. Although AV1 was alone in the toddler classroom, given the layout of the preschool bathroom allowed staff persons to see into the area to keep children within sight while allowing privacy from other children, and that when SP1 and SP4 became aware AV1 was no longer using the bathroom, SP1 went through the bathroom area and into the toddler classroom where AV1 was found alone, there was not a preponderance of the evidence that SP1 and SP4 failed to provide AV1 with necessary care or failed to protect AV1. It was not determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years.
Allegation Two: During the course of this investigation, it was reported that AV2 and AV3 were on one side of a partitioned gym without staff person knowledge or supervision for approximately four minutes. The facility’s Risk Reduction Plan stated, “During gym time, if other [community] members are utilizing the gym, the divider curtain (blue) will be lowered and all children and [staff persons] will stay together on half of the gym. [Staff persons] will position themselves strategically so that all children are in view at all times.” The Facility’s Supervising for Safety and Risk Management policy stated that staff persons should “Always know how many and which children are in your care and always place yourself in a position where you can see all of the children in your care.” FM2 provided this investigator with a screen shot of a voicemail from SP1 on February 1, 2024, at 5:50 p.m. The screenshot read, “[AV2] and a classmate ran on you know the other side of the curtain that separates the gym, ran out the back door and we’re (sic) just caught by a [community] member before our teacher could catch up to them.” FM2 had no prior concerns. FM3 had not heard of the incident involving AV3 but stated s/he had previously seen other children pedal bikes to the other side of the gym and staff persons got them right away. FM3 stated AV3 liked to ride the bikes, and FM3 had no prior concerns with the facility. The facility’s Internal Review stated that on February 1, 2024, the preschool and toddler classrooms went to the gym to play toward the end of the day. SP2 was responsible for the toddler classroom and SP3 was responsible for the preschool classroom at that time. SP1 entered the gym with infant children in a stroller, including SP2’s child (C). SP2 took the C out of the stroller and put him/her in a toy car and began to push the C around. At 3:06 p.m., AV2 and AV3 were on a bike with a passenger seat, and they pedaled around the curtain to the other side of the gym. A community person (CP) walked by and notified the staff persons that AV2 and AV3 were on the other side. At 3:10 p.m., SP2 and SP3 performed a head to face count and made sure everyone was accounted for. SP1 placed the C back in the stroller and left the area. SP1 provided the following information: · On an unknown date in February 2024, SP2 was in the gym with the toddler classroom and SP3 was in the gym with other children. SP1 brought the infant children to the gym in a stroller, and SP2 took the C out of the stroller. · AV2 and AV3 were on a bike that had a passenger seat. They went on the other side of the curtain. The CP poked his/her head around the curtain and told staff persons that there were children on the other side of the curtain. SP2 “popped” up and went to the other side to grab AV2 and AV3. SP1 said AV2 and AV3 seemed “fine” when they returned. SP2 told SP1 and SP3 that s/he thought AV2 and AV3 had already been picked up. SP1 set the C back in the stroller and then left the gym. · Upon reviewing the video footage, SP1 saw AV2 and AV3 pedal the bike over to the other side of the curtain. There was a time when they were not in view due to the camera angle. From the camera in the hallway outside of the side door to the gym, the CP was seen coming out of the locker room, then the CP went to the side door opened it and shut it, then the CP walked to the main gym door and let SP2 know there were two children on the other side of the curtain. SP1 said based on video footage, AV2 and AV3 were unsupervised on the other side of the curtain for approximately four minutes and did not leave the gym. · SP1 stated that when classes were combined, the supervision was “ultimately” the responsibility of the staff person in charge on the roster for that staff person’s assigned classroom. Staff persons for the preschool and toddler classrooms participated in shared supervision of children, as the children from both classes played together; however, the responsibility for supervision, particularly the children’s whereabouts, rested firmly with the staff person assigned to that class.
SP2 provided the following information: · Sometime in February 2024, SP2, SP1 and “a couple other [staff persons]” were in the gym with around 20 children. SP2 was the teacher of the toddler classroom, and while the group was in the gym, AV2 and AV3 went on the other side of the blue “wall” on bikes. · A CP entered the gym though the main door and let the staff persons know AV2 and AV3 were on the other side and pointed to the side door. SP2 ran over there and found AV2 and AV3 still on the bike and “calm.” SP2 said that children went over to that side “all the time” and staff persons followed them to have eyes on them. · SP2 stated this “got blown out of proportion” and that AV2 and AV3 were in the gym the whole time. SP2 stated it was maybe a “a minute or two” that AV2 and AV3 were over there. SP2 was told by management (who had reviewed video footage) that AV2 and AV3 were over there for five minutes and that they got down the hallway and the CP brought them back into the gym. · SP2 stated that the C was in the gym at the time and SP2 was talking to the C at the time of the incident. SP2 stated that there were other staff persons in the gym as well, and that AV2 and AV3 rode the bike past them. SP4 said that when SP2’s children (AV1 and the C) were in the same space SP2 was in, SP2 directed his/her attention to them. SP4 stated each classroom staff person was “always” responsible for supervising the children in his/her classroom, no matter the location of the group, unless another arrangement was made (for example if a staff person needed to use the bathroom and asked another staff person to cover supervision momentarily). P1, P2, and P4 had no first-hand knowledge of the incident, but P1 stated there were no other concerns regarding SP2. This investigator was not able to review video footage. Conclusion Allegation Two: Consistent information was provided that SP1, SP2, and SP3 were in the gym with their respective classes, when AV2 and AV3, who were in SP2’s toddler class, pedaled on a bike to the other side of the gym behind the curtain and out of sight of staff persons. Video footage showed that AV2 and AV3 were on the other side of the curtain for approximately four minutes and did not leave the gym. SP2 was notified by the CP that AV2 and AV3 were on the other side of the curtain by the side door. AV2 and AV3 were then returned to the group unharmed. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual when: (1) at the time of the incident, the individuals were performing duties identified in the center's child care program plan; (2) the individuals had not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individuals had not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individuals providing services were both in compliance with all licensing requirements relevant to the incident. Although SP1 and SP3 were also in the gym at the time of the incident, information from SP1, SP4, and the facility’s Supervising for Safety and Risk Management was consistent that the facility’s practice was that each staff person was responsible for the supervision of the children in the classroom the staff person was assigned to work in. AV2 and AV3 were enrolled in the toddler classroom and SP2 was the staff person responsible for the toddler classroom at the time of the incident, therefore SP1 and SP3 were mitigated from their responsibility to supervise AV2 and AV3 during that time. AV2 and AV3 being on the other side of the curtain for approximately four minutes without staff person knowledge or supervision was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although AV2 and AV3 were unsupervised on the other side of the curtain, SP2 was engaged with other children at the time AV2 and AV3 went to the other side of the curtain, and at that time there were no community members using the other side of the gym. Therefore, SP2’s actions and conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) at the time of the incident, SP2 was performing job duties as required by the facility’s policies; (2) SP2 had not been determined responsible for a similar incident that resulted in a finding of maltreatment; (3) SP2 had not been determined to have committed a similar nonmaltreatment mistake under this paragraph; (4) there were no injuries to AV2 or AV3 as a result of this incident; (5) except for the period when the incident occurred, the facility and SP2 were both in compliance with all licensing requirements relevant to the incident. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate, but not followed by SP2. All staff persons reviewed the facility’s supervision policies. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not determined as a perpetrator of maltreatment of AV2 and AV3 because the Department of Human Services found that the incident for which SP2 was responsible met the criteria to be determined a nonmaltreatment mistake. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP2 is responsible might not be considered a nonmaltreatment mistake. On July 10, 2024, the facility was issued a Correction Order for the violations outlined in this report and for failure to report suspected maltreatment as required. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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