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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.” On June 18, 2025, most of the children and family work, including investigations of maltreatment at childcare centers, at the MN Department of Human Services (DHS) Office of Inspector General transferred to the new Minnesota Department of Children, Youth, and Families (DCYF), as directed by state law. While this investigation began under DHS, pursuant to Minnesota Statutes, section 15.039, subdivision 2, this Investigation Memorandum is being issued by DCYF pursuant to that transfer.
License Number and Program Type: 1062800-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families Judith.schwanke@state.mn.us. Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised on a playground for approximately 30 minutes. Date of Incident(s): May 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 May 15, 2025; from documentation at the facility; and through four interviews conducted with the AV’s family member (FM), a supervisory staff person (P), SP1 and SP2. Facility documentation showed the AV was 3 years and ten months old and enrolled in the Hippo preschool classroom at the time of the incident. This investigator met with the AV and the AV did not provide information relevant to this investigation. The facility was a stand-alone building located in an industrial area with businesses on all sides. To the east of the facility was a road with a speed limit of 20 miles per hour. The facility had two playgrounds separated by a chain link fence and a gate with an unlocked fork-latch. The fence on the north side of both of the playgrounds was approximately six feet high and the remaining fencing was approximately four feet high. The playground to the west was not in use. From that playground there was an unlocked double gate that led to a shared parking lot and a door that went directly into the Hippo classroom. The playground to the east was covered with rubber mulch and had a small grass area. In the mulch area there was a large climbing structure with a semi-enclosed top and multiple slides, two small climbers, two benches, trees, and assorted toys. The fence between the east playground and the road had a gate with an unlocked fork-latch. The FM stated that on an unspecified date, a facility staff person told him/her that the AV had been left outside on the playground for approximately 30 minutes. The FM stated that “everything” was “good” and not to “worry” about the incident because “nothing happened” to the AV. The FM did not know the names of the staff persons involved, but stated they “loved” the AV and gave the facility “five stars.” The P provided the following information during his/her interview: · On May 2, 2025, the P was not at the facility and received a phone call from a facility staff person who told him/her that the AV had been left on the playground when the group transitioned indoors. The P returned to the facility, arriving at approximately 12 p.m. · SP1 told the P that the group had been on the playground and transitioned indoors. Once inside the children got ready for lunch. SP1 and SP2 prepared 17 plates for lunch and noticed that two plates were not used. SP1 told the P that s/he “knew” there were 16 children present and one child absent. As the children were eating, SP2 realized s/he left his/her water bottle on the playground. SP2 went to the playground to get his/her water bottle and “discovered” the AV on the playground. · SP2 told the P that s/he “knew” there were 16 children in attendance and SP2 prepared 17 plates for lunch. There were “extra” lunch plates and SP2 did not think anything of it. Then SP2 went to the playground to get his/her waterbottle and saw the AV. The AV was calling out SP1’s name. SP2 hugged the AV and brought him/her into the classroom and the AV sat down to eat lunch. · The P reviewed video footage of the incident and saw that at 11:19 a.m., SP1 called the children to line up along the playground fence and the AV and three other children went to a climbing structure. SP1 stood near the fence and the AV stayed at the climbing structure while the three children that were with the AV lined up along the fence. One child looked back at the AV and “smiled.” SP2 faced the fence and SP1 opened the gate between the two playgrounds and walked through followed by the children. SP2 “half looked” over his/her shoulder at the playground and at 11:20 a.m., went through the gate. SP1, SP2 and the children were no longer visible. The AV played on the climbing structure, went down a slide, walked to a corner of the playground and “paced around” the playground. At 11:52 a.m., SP2 opened the gate between the playgrounds and covered his/her mouth with his/her hands. The AV walked to SP2 and SP2 took the AV’s hand and bent down for a moment, then they walked to the gate. · When transitioning children from the playground to the classroom, staff persons were trained to line the children up by the fence and count the children. Staff persons used an “accountability sheet” with the names of all children in attendance highlighted to know how many children were present. One staff person was at the front of the line and opened the gate and the children walked through the gate with another staff person at the end of the line. Then the group walked to the classroom door and stood along the wall of the building and a staff person counted the children again. Then the group went inside and staff persons counted the children again. Staff persons were trained to complete a “meal count” at the time of food service for meals. · The P did not look at the Hippo classroom “accountability sheet” after the incident and the accountability sheet was shredded prior to the DCYF investigator’s site visit. The P looked at the Hippo classroom meal count sheet for May 2, 2025, and there were no attendance or meal counts written in for the day. SP1 provided the following information during his/her interview: · On May 2, 2025, at approximately 11:25 a.m., as the children moved from the east playground to the unused west playground, the children got “rowdy.” Before leaving the playground, SP1 counted the children at the fence but some children “dispersed,” and s/he “miscounted.” SP1 counted the children by “gently touching” each of their heads and saying the number aloud. SP1 did not look at the accountability sheet that was in his/her pocket. SP1 did not recall how many children s/he counted but thought there were 15 children present. · When the group arrived at the classroom door, SP2 opened the door and children went in and SP1 was at the end of the line. SP1 was “not sure” if SP2 counted the children when they went into the classroom. When the children arrived to the classroom, they took off their jackets and either read books on their own or SP1 read a book to them while SP2 set up lunch. After SP2 set up lunch, s/he went to the playground to get his/her water bottle. At approximately 11:50 a.m., SP2 returned with the AV. SP1 asked the AV if s/he was okay and the AV did not respond. SP1 told the AV s/he was “sorry,” and that s/he did not know the AV was still outside. · SP1 did not count the children when the group returned to the classroom and did not receive “solid” training on what to do when the group transitioned from outdoors to inside. SP2 provided the following information during his/her interview: · On May 2, 2025, at approximately 11:20 a.m., SP1 and SP2 “yelled” to the children to line up by the fence because it was time to go inside. SP2 stated there was “a lot of redirecting” to get the children to the fence. SP2 looked at the playground and it “seemed like” all the children lined up. SP1 opened the playground gate and the children went through to the west playground. While SP1 gathered children that were running around that playground, SP2 shut the gate between the playgrounds and looked behind him/her but did not see any other children in the east playground. · SP2 did not recall who opened the classroom door when the group went inside. Once the group was in the classroom, the children took off their jackets and sat on a carpet while SP1 read them a story. SP2 got lunch ready and at approximately 11:50 a.m., s/he realized s/he left his/her water bottle on the playground. SP2 went to the gate between the two playgrounds and saw the AV playing with his/her fingers and heard the AV say SP1’s name. The AV saw SP2 and walked toward him/her and SP2 ran to the AV and said, “Oh my gosh.” SP2 then grabbed his/her water bottle and took the AV into the classroom. When SP2 and the AV arrived in the classroom, SP1 said, “Oh my God.” Then the AV sat for lunch and SP2 sat with him/her. SP2 asked the AV where s/he was when the group lined up but the AV did not respond and did not want to eat. · SP2 was trained to count the number of children and complete name to face attendance by reading the list and saying a name, and looking at the child to be sure they were present before going inside. SP2 did not think name to face was completed,” because the list of children present was not taken to the playground. SP2 did not talk with SP1 about not having the list and they each “knew” there were 16 children present. The meal count sheet for the Hippo classroom showed that on May 2, 2025, there were 16 children present, including the AV. The lunch count was 15. The facility provided a video segment of the incident. The segment from May 2, 2025, was timed stamped and did not have audio. The video provided the following information: o At 11:18:31 a.m., four children ran to the fence between the two playgrounds. SP1 and SP2 slowly walked toward the fence and more children ran to and from the fence. The AV was at the top of the large climbing structure and another child sat on the slide of the structure. o At 11:19:18 a.m., four children, including the AV, were on the climber, twelve children stood along the fence and SP1 and SP2 stood behind them. o At 11:19:25 a.m., SP2 turned and looked toward the climber and s/he appeared to yell to the children because his/her mouth moved. Simultaneously, SP1 opened the gate between the two playgrounds. The twelve children ran into the unused west playground followed by SP1 and three of those children ran around that playground. The three children who were on the climber with the AV, went off the climber and ran to and through the gate followed by SP2, then SP2 shut the gate. o The view of the classroom door was obstructed. o At 11:21:26 a.m., the AV slid down from the top of the climber and walked toward the fence between the playgrounds. The AV stopped and stood with his/her hands in his/her jacket pocket and then walked to the gate. o At 11:23:30 a.m., the AV turned from the gate and walked to one of the benches. On the bench was a water bottle and the AV touched the top of the bottle and shook the bottle. The AV then placed the bottle back on the bench and walked to the gate between the playgrounds and looked toward the classroom door. o At 11:28:25 a.m., the AV put up the hood of his/her jacket and then walked around the playground. o At 11:29:10 a.m., the AV tripped and fell to the ground. S/he got up and walked around toward the climbers and out of camera view. o At 11:31:14, the AV walked back into camera view and walked to the gate between the playgrounds and kicked the gate 17 times before s/he turned and walked toward the climbers again. o At 11:35:24 a.m., the AV walked out of camera view. Seven seconds later s/he walked back into camera view and walked to the gate and around the playground. o At 11:42:14 a.m., the AV walked out of camera view and at 11:47:50 a.m., walked into camera view near the large climber and then walked around the playground. o At 11:50:13 a.m., the AV ran out of camera view. o At 11:52:32 a.m., the AV walked into camera view as SP2 arrived to the playground gate. SP2 opened the gate and put a hand to his/her mouth. S/he walked to the bench and picked up the water bottle as the AV walked toward him/her. SP2 then brought the AV back toward the facility building. Then the AV and SP2 moved out of camera view and the video ended. The facility’s Program Plan stated that children were supervised by a staff person at all times. The facility’s Risk Reduction Plan stated that when children transitioned to and from the playground, staff persons counted the children prior to leaving one location and “immediately” when they reached the destination. Staff persons used written attendance and a tablet roster for “name to face” counts and checks. Staff persons lined up children and completed a name to face count using an “accountability sheet” and a tablet. One staff person positioned themselves at the front of the group and one at the rear, to ensure all children remained with the group. Staff persons maintained continuous counts and a written accountability roster and tablet with a list of the children in attendance at all times. The facility’s Employee Handbook stated that every classroom had a system for “constantly” monitoring and tracking the name and number of children in the room. Every staff person was responsible for knowing the number of students in their room. Facility documentation showed that the P, SP1, and SP2 each received training on the facility’s Program Plan, Risk Reduction Plan, Employee Handbook, and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 142B.01, subdivision 27 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: A. Maltreatment: Information was consistent that on May 2, 2025, the AV was on the playground for approximately 30 minutes without the knowledge or supervision of SP1 and SP2 which was a violation of Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP2 returned to the playground to get his/her waterbottle and found the AV on the playground and brought him/her inside to the Hippo classroom. Although SP1 stated that s/he counted the children at the playground fence, SP1’s count was inaccurate and neither SP1 nor SP2 counted the children upon arrival to the classroom, which left the AV, who was 3 years and 10 months old, unsupervised on the facility playground for 31 minutes before being found by SP2. When SP2 found the AV, neither SP1 nor SP2 was aware that the AV was missing. Given that the AV was visible and accessible to passersby; that the location of the playground exposed the AV to community persons, vehicle traffic, and other hazards; that it was unlikely the AV would be able to provide for him/herself in an emergency and that staff persons were not aware the AV was on the playground in the event of any emergency; there was a preponderance of the evidence that there was a failure to supply the AV with the necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical health when reasonably able to do so. It was 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). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1 and SP2 were each trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies and procedures including the Program Plan, Risk Reduction Plan and Employee Handbook. At the time of the incident, SP1 and SP2 were working in the Hippo classroom and were each responsible for the care and supervision of all the children in the classroom, including the AV, and responsible for ensuring all the children were present after transitioning from the playground to the classroom. SP1 and SP2 were each responsible for maltreatment of the AV. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Children, Youth, and Families for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that their policies were adequate but not followed by SP1 or SP2. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The Department of Children, Youth, and Families informed the Department of Human Services, Office of Inspector General, Background Studies Division that SP1 and SP2 were each determined responsible for maltreatment. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On September 26, 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 Children, Youth, and Families.
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