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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: 1103755-CCC (Child Care Center) Investigator(s): Judie Schwanke judith.schwanke@state.mn.us Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the classroom without staff persons’ (SP1 and SP2) knowledge or supervision and was unsupervised for approximately eight minutes. Date of Incident(s): April 2, 2025 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 April 10, 2025; from documentation at the facility; and through six interviews conducted with the AV’s family members (FM1 and FM2), and four facility staff persons (P1, P2, SP1, and SP2). This investigator met with the AV but because of his/her age, s/he was not able to provide information pertaining to this investigation. Facility documentation showed that the AV was two years and three months old and enrolled in a toddler classroom at the time of the incident. The facility consisted of seven classrooms, including two toddler classrooms and three preschool classrooms, off of an L shaped hallway. The AV’s classroom was located in the middle of the hallway with a preschool room on one side and another toddler classroom on the other side. Beyond that toddler classroom, at the end of the hallway, was a storage area for the facility’s strollers and buggies. At the other end of the hallway was a facility office and front door. There were two additional exit doors in the hallway that required a key fob to open. The toddler classroom was square with a large column near the door and tables to the right. The classroom bathroom was to the left of the doorway and separated from the room with a half wall. The preschool classroom was rectangular. Throughout the room were shelves and on one shelf were toy trucks and cars. The preschool classroom was unoccupied at the time of the incident. FM1 and FM2 provided the following consistent information: · FM1 stated that the AV was a “runner,” and FM2 stated that the AV liked to run, and be ran after. · On April 2, 2025, P1 called FM1 and told him/her that SP1 and SP2 did not put up a gate and the AV left the classroom. When they noticed the AV was not in the classroom, they looked for him/her and the AV was found in the preschool classroom “down the hall.” The AV was unsupervised for approximately three minutes and when s/he was found, s/he was “fine and happy.” · When FM1 picked up the AV that day, SP1 “was tearful” when s/he talked with FM1. SP1 told FM1 that they had been “working on” keeping the door closed or “putting up” the gate but s/he let her “guard down” because the AV had been “listening better” and “staying with the group.” · On April 3, FM2 picked up the AV and talked with SP1. SP1 told FM2 that s/he watched the video of the incident and saw the AV walk to the door, turn and look, and when no one came after him/her, s/he went to play with cars. FM2 told SP1 that sounded like the AV and that the AV “loves” to be “chased.” SP1 apologized to FM2. · Prior to this incident, neither FM1 nor FM2 had concerns regarding the facility. P1, P2, SP1, and SP2 provided the consistent information: · On April 2, 2025, at approximately 9:15 a.m., SP1, SP2, and twelve children, including the AV, were in the toddler classroom finishing breakfast. SP2 was not typically in that classroom but was a float staff person. SP2 assisted children at the tables and cleaned the tables while SP1 assisted children in the bathroom area and changed diapers. SP1 stated that when s/he was in the bathroom area s/he could not “see the [classroom] door.” On the day of the incident, the classroom door to the hallway was open. SP2 stated that “generally” the door was open but there was a gate put in the open doorway to keep the AV in the classroom because in the past, the AV has left the classroom. Prior times when the AV left the classroom, s/he usually went to the buggy area. · SP2 walked around the tables and wiped them and supervised children that were at a carpet near the tables. · SP1 stated that when s/he came out of the bathroom area, s/he “immediately” knew the AV was “gone.” SP1 asked SP2 where the AV was and SP2 said, “Not here.” SP1 left the classroom, went to the buggy area but did not see the AV there, so s/he walked to the preschool classroom, looked inside but did not see the AV. Then SP1 went to the facility office and asked P1 if s/he had seen the AV. P1 told SP1 that s/he had not so SP1 and P1 each left the office to look for the AV. SP1 walked down the hall, stopping in other rooms to “alert” other staff persons that s/he was looking for the AV. SP2 stated that while SP1 was out of the classroom s/he looked for the AV in cubbies and behind an easel and supervised the other children in the classroom. P1 looked into each room through windows in the hallway and looked in a bathroom. SP1 then arrived back at the classroom and asked SP2 if s/he found the AV and SP2 had not. · P2 was in a classroom that adjoined the preschool classroom. P2 saw SP1 “frantically” going down the hall and then come right back. P2 asked SP1 if everything was “okay,” and SP1 told P2 that s/he was looking for the AV. P2 “knew” that the preschool classroom was empty and s/he had a “gut feeling” s/he would find the AV there so s/he went in to that classroom. P2 found the AV “happily” playing with cars on the floor. P2 then picked up the AV and told him/her that they needed to go find SP1 and they walked to the toddler classroom. · P1 was in the hallway near the toddler classroom when P2 and the AV walked into the hallway. P1 asked P2 where s/he found the AV and P2 told P1 that s/he found the AV in the preschool room playing with cars. Then P1 went to the office to review video footage of the incident and P2 took the AV into the toddler classroom and told SP1 that s/he found the AV in the preschool classroom playing with cars. SP1 stated the AV was calm and seemed “fine.” SP1 estimated that the AV was out of the classroom and unsupervised for approximately three minutes. · P1 stated that prior to this incident, there had been a similar incident when a child left a classroom through an open classroom door. After that incident, P1 “believed” s/he sent a group text, an email, and told some staff persons that classroom doors should be shut. P1 was not able to find the group text or email and did not think s/he told SP1 and SP2 that the toddler classroom door should be shut. · P2 stated that after the prior incident, staff persons in that classroom were told to keep classroom doors closed. P2 stated that SP1 and SP2 “knew” the classroom door should be shut because the classroom was for younger children and the door was “pretty shut all the time.” When the toddler classroom door was open, a gate was to be put in the doorway. · SP1 stated that prior to the incident s/he was not told that the classroom door needed to be shut and the gate was a “compromise” to having the door open. On the day of the incident, SP1 did not “know why” the gate was not up. · SP2 stated that prior to the incident there had been “comments” about keeping doors shut. S/he was not “sure” that s/he remembered being told to “keep them always closed,” but remembered that it was “mentioned” that it “was good to keep them closed.” On the day of the incident, SP2 did not shut the door and followed SP1’s “lead” and left the door open. The facility provided video segments of the toddler classroom, the hallway, and the preschool classroom. The videos were time and date stamped but did not contain audio. The videos provided the following information: o At 9:18 a.m., the hallway and the preschool classroom were empty, in the toddler classroom children were seated at tables and other children were throughout the room. A family member was in the classroom with his/her child. The AV played on a carpet between the table and the bathroom area. SP1 was in the bathroom area and SP2 stood near the tables. The classroom door to the hallway was open. Approximately one minute later, the family member walked out of the classroom and the door remained open. o At 9:20:34 a.m., the AV walked from the carpet area to the classroom door. SP1 was not visible in the bathroom area and SP2 was cleaning near the tables. o At 9:20:38 a.m., the AV walked out of the classroom door and into the hallway. The AV stood in the middle of the hallway just outside of the classroom for approximately 20 seconds. Then the AV ran down the hallway toward the buggies. The AV stopped at the end of the hallway and looked back toward the toddler classroom. o At 9:21:22 a.m., the AV left the buggy area and ran down the hallway toward the toddler classroom. The AV passed the toddler classroom and ran into the preschool classroom. The AV walked toward the back of the classroom and then stopped and looked around. Then s/he walked toward a toy shelf, grabbed a toy and placed it on the carpet and sat down on the carpet in front of the toy shelf. In the toddler classroom, SP1 was still in the bathroom area and SP2 cleaned up the table area. o At 9:23:05 a.m., SP1 walked out of the bathroom area to the children and then sat down on the carpet. Then SP1 stood and went back to the bathroom area and walked between the two areas. SP2 had his/her back to the children and stood at a counter in the classroom. In the preschool classroom, the AV played on the floor. o At 9:25:17 a.m., SP1 was at the carpet and SP2 sprayed the tables and turned to look at SP1. SP1 then walked out of the classroom and into the hallway. S/he walked down to the buggy area, turned and walked down the hallway past the toddler classroom and out of camera view. In the toddler classroom, SP2 walked around the classroom and then SP1 walked into camera view and back to the toddler classroom and stood in the doorway. o At 9:26:30 a.m., SP1 walked down the hall toward the preschool classroom, walked into the preschool room, and back out. SP1 then walked down the hallway and in and out of other classrooms. In the preschool classroom, the AV played on the carpet. o At 9:28:07 a.m., P2 walked into the preschool classroom and toward the back of the classroom and the AV. S/he bent down and picked up the AV. P1 and SP1 walked down the hallway toward the toddler classroom. P2 walked into the hallway with the AV and SP1 and P1 turned and walked toward them. P2 put the AV down at the toddler classroom doorway and turned and walked back down the hallway. SP1 and the AV went into the classroom and SP1 put a safety gate in the classroom doorway. The AV walked to the gate and SP1 picked him/her up, hugged him/her, and carried him/her to the carpet and the videos ended. The facility’s Program Plan stated that children were supervised at all times through the day. The facility’s Risk Reduction Plan stated that “children must be within site and sound at all times,” and staff persons “make sure” doors were closed after the last child has gone through. Facility documentation showed that P1, P2, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s Program Plan and Risk Reduction Plan. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: Information from all sources including video was consistent that on April 2, 2025, the AV left the toddler classroom through an open door without staff persons’ knowledge or supervision which was a violation of the facility’s Program Plan and Risk Reduction Plan, and Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV walked down the facility hallway to the preschool classroom while SP1 and SP2 were engaged in activities in the classroom. After approximately five minutes, SP1 noticed that the AV was not in the classroom and left the classroom to look for him/her. SP2 looked in the classroom for the AV. Eventually P2 found the AV in the preschool classroom and returned him/her to the toddler classroom unharmed. The AV was out of the classroom unsupervised for approximately eight minutes. 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. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan required under Minnesota Rules, part 9503.0045; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has 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 individual providing services were both in compliance with all licensing requirements relevant to the incident. Consistent information was provided that neither SP1 nor SP2 closed the classroom door or placed the gate in the doorway. SP1’s and SP2’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1 and SP2 were performing job-related duties. SP1 was assisting children in the bathroom and SP2 was engaged with children who were eating and was cleaning after breakfast.
(2) SP1 and SP2 each had not been determined responsible for any previous nonmaltreament mistake under this paragraph; (3) SP1 and SP2 each had not been determined responsible for any previous incident that resulted in a finding of maltreatment; (4) The AV was uninjured and did not require medical care after the incident; and (5) Except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP1 and SP2 was not maltreatment. 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 determined that their policies and procedures were adequate and followed by SP1 and SP2. The facility updated their policies and procedures that all classroom doors will remain closed at all times. All staff persons at the facility were retrained on the new policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were each not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP1 and SP2 were each responsible met the criteria to be determined a nonmaltreatment mistake. SP1 and SP2 were each notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1 and SP2 were responsible might not be considered a nonmaltreatment mistake. On June 6, 2025, the facility was issued a Correction Order for the violation outlined in this report. 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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