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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: 1035184-CCC (Child Care Center) Investigator(s): Van Mulheron Minnesota Department of Children, Youth, and Families 651-539-8253 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was found in a vestibule by a community person and was without two staff persons’ knowledge or supervision for approximately eight minutes.
Date of Incident(s): July 15, 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 July 30, 2025; from documentation at the facility; and through eight interviews conducted with two supervisory staff persons (P1 and P2), four staff persons (P3, P4, SP1, and SP2), a community person (CP), and the AV. P2 was also the AV’s family member. The facility was located within a Lutheran Social Services building that was open to the public and had a reception desk near the front entrance. The facility had three secured entrances within the building that required either a badge or a code to enter. There was an entrance by the reception desk, which opened into the main hallway of the facility. The main hallway had a parent entrance and past that entrance was another secure door that opened into a vestibule which remained locked and required a security badge to open. The vestibule was “L” shaped and had another set of doors that had stairs that led into an apartment complex and a set of unlocked doors that opened onto a sidewalk that led to the playground and the road. The vestibule was also used to store an infant buggy. The facility had classrooms and administration offices on the same side of the main hallway as the parent door. On the other side of the hallway was the older preschool classroom, staff bathrooms, and a kitchen. Another hallway wrapped around those rooms and connected to the main hallway. The other hallway had three additional classrooms, including the younger preschool classroom and the children’s cubbies in the hallway. Across from the kitchen, near the doors to the vestibule, there was a gym.
At the time of the incident the AV was four years old and enrolled in the younger preschool classroom. The AV said that s/he was outside with his/her classroom, SP1, and SP2 and that s/he was left outside and his/her classroom left without him/her. When the AV was outside some people came and “saved” him/her. The CP provided the following information · On July 15, 2026, the CP walked through the doors from the apartments into the vestibule and saw the AV. The CP was unsure if the AV was with the facility or lived in the apartment building. The AV did not answer any questions when asked where s/he came from. The CP walked the AV out of the vestibule and around the front of the building and into the facility. · The CP was with the AV in the hallway when an unknown staff person arrived. The CP said s/he was not able to talk with the staff person but that the staff person took the AV “brusquely” by the arm, “scolded” the AV and then walked away with the AV. The CP heard the staff person say, “What are you doing?” · The CP and P2 then watched video footage of the vestibule and saw the following: Three to four staff persons entered the vestibule with a group of children. A staff person unlocked the facility’s door and the staff persons and the children began to walk into the facility. The AV placed him/herself in a corner of the vestibule by the apartment doors. The AV had an interaction with another staff person and then that staff person walked past the AV and into the facility. There was another staff person across from the AV who was not facing the AV, but that staff person was the last person who walked into the facility. It did not appear that last staff person checked the vestibule for any other children. The AV was unsupervised in the vestibule for eight minutes before the CP found the AV. P2 provided the following information in his/her interview and in his/her written statement: · On an unspecified date at approximately 4:25 p.m., P2 was in the office when the CP came in, without the AV, and said s/he found a child in the vestibule. P2 watched the video with the CP and said that it was the AV. P2 said that the video footage was approximately eight minutes from 3:51 to 3:59 p.m. P2 saw all the children enter the vestibule before any staff person. P3 walked to the front of the line followed by SP1. SP2 held the facility door open and SP1 entered the building followed by P3 and the children. As the children walked inside, the AV sat down in the corner of the vestibule. SP2 then walked inside with P4 and shut the door without looking behind him/her. · P2 checked on the AV and the AV said that s/he was, “Okay.” P2 checked the Child Supervision Log and saw there were no transitions documented on the day of the incident. P2 did not speak with any staff persons that day but reported the incident to P1. P2 had no prior concerns about SP1 or SP2. SP1 provided the following information in his/her interview and in his/her written statement: · On an unspecified date in July 2025, SP1, SP2, and the younger preschool classroom, including the AV, returned to the facility after going for a walk. On the sidewalk next to the playground, the younger preschool classroom joined the older preschool classroom, P3, and P4. It was decided that both classrooms would go to the gym to see if it was open to use. SP1 said that SP2 had the clipboard and thought SP2 completed the name to face check of the children. · Both classrooms, including the AV, entered the vestibule. P3 opened the door and another staff person inside the facility held the door open. P3 entered the facility followed by SP1. SP1 said that s/he would “normally” complete a head count of the children as they went through the doors but on that day, there were too many children going through, so SP1 led the way to the gym. SP1 said that SP2, P4, and the staff person holding the door open behind him/her “had it covered” since they were at the end of the line. · When both classes arrived outside the gym, the gym was being used by another classroom. P4 then left the group and went to the bathroom. It was decided that both groups would go to the younger preschool classroom until the gym was free for them to use. P4 joined the group when they entered the younger preschool classroom and then SP1 walked into the hallway. · As SP1 placed clothes into the children’s cubbies s/he saw the AV running in the main hallway and yelling, “I am going to my [sibling’s] classroom!” SP1 thought that the AV ran out of the classroom door behind him/her. SP1 ran to the main hallway and saw two community persons behind the AV. SP1 caught the AV and the AV said again, “I am going to see my [sibling].” SP1 heard one of the community persons say that the AV was, “Okay” and SP1 replied, “Okay.” SP1 then “grabbed” the AV’s arm and took the AV back to the classroom. SP1 could not find P1 or P2 to tell them that the AV had run out of the classroom. · SP1 said that the next day P2 told him/her that the AV was in the vestibule for eight minutes. SP1 said that s/he did not know that the AV was unsupervised but that the AV had ran out of the classroom in the past and that was what SP1 thought had happened the day of the incident. SP2 provided the following information in his/her interview and in his/her written statement: · On an unspecified date SP1 and SP2 took the younger preschool classroom, including the AV, on a walk around the block. At approximately 3:45 p.m., the class returned to the facility and was on the sidewalk next to the playground with the older preschool classroom, P3, and P4. SP2 said that s/he held the clipboard but SP1 had the attendance sheet and completed a head count of the children before both classrooms walked toward the vestibule together. · SP1 opened the door to the facility. Another staff person inside the facility held the door open while SP1 and P3 entered the facility followed by the children. SP2 was near the end of the line while P4 was at the end of the line. SP2 said that s/he saw the AV in the vestibule behind the buggy but thought that P4 would grab the AV since s/he was at the end of the line. SP2 was focused on the children in front of him/her. · Once inside the facility both the classrooms walked to the gym to see if it was open to use. When the classrooms were outside the gym SP2 told SP1, P3, and P4 that s/he was going to the bathroom and then left. When SP2 returned to the gym both classes were in the younger preschool classroom. When SP2 entered the younger preschool classroom SP1 entered the classroom with the AV. The AV appeared “fine” and ran to join the other children that were dancing. SP2 said that s/he did not know that the AV was missing until 6 p.m. when P2 told him/her. · SP2 said that s/he was trained that only lead teachers completed the name to face count and complete the attendance checklist. SP2 did not see or use the attendance checklist the day of the incident. P3 said that on an unspecified date s/he, P4, and the older preschool children entered the vestibule at the same time as SP1, SP2, and the younger preschool children, including the AV. P3 entered the facility first followed by SP1 and SP3, with P4 at the end of the line. Both classes went to the gym but were not able to use it as another class was inside. P3 and P4 joined the young preschool classroom in their room. P3 then left for the day since the older classroom had only 10 children. P3 did not know that the AV was missing until the next day. P4 said that on an unspecified date s/he, P3, and the older preschool classroom entered the vestibule at the same time as the younger preschool classroom, including the AV, SP1, and SP2. P3 opened the door followed by some children and SP1. P4 saw the AV hide behind the buggy and P4 tried to get the AV to come out but his/her children were walking into the building, and s/he followed the children as s/he was responsible for recording their transition. P4 did not tell SP2 that the AV was by the buggy but P4 “thought” that SP2 would grab the AV. Once inside P4 did a count of his/her classroom and then took the older preschool children to their classroom. P4 said that it was after 5 p.m. when P2 told him/her that the AV was left in the vestibule. P1 provided information that was consistent with P2, SP1, and SP2. P1 had no prior concerns about SP1 or SP2. The facility’s Risk Reduction Plan and Supervision Policy stated: · “Children are always accompanied by staff or parents when outside the center's locked doors.” · “All children must be supervised and accounted for at all times. At transitions from one space to another, staff [persons] must complete the name to face Child Supervision Log of the children as they leave and as they arrive at the new space to make sure that no children are missing. On walks, children must be under constant supervision. On walks and field trips, each child must be assigned to one of the accompanying adults who must keep track of their assigned children at all times. Children are not left in the community without supervision” · “When children make a transition from one space to another, staff must do a name to face count as they leave and as they arrive at the new space. When two staff members are present, one member must be at the front of the line and the other at the end of the line. All children must be accounted for at all times. The use of Child Supervision Logs was also required before and after all transitions at the [facility].” The facility’s Child Supervision Log stated that staff persons were to: · “Immediately before leaving an area (for example: classroom, large muscle room, play ground or the site of a field trip) with a group of children complete the following two steps: Count the number of children present and match it to the count on the log before leaving the area, write in the number of children for the transition in the appropriate column. Verbally call out (say) the child's name and match it to the child's face. When all children on the log are accounted for and the number of children matches the number of children on the log, the group can move to another area.” · “Immediately upon arrival at the next area, perform the following two steps: Count the number of children present and match it to the count on the log, write in the number of children for the transition in the appropriate column. Verbally call out (say) the child's name and match it to the child's face. When all children and the log are accounted for and the number of children matches the number of children on the log, the group can go on with the activity.” Facility documentation showed that P1 – P4, SP1, and SP2 each received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and Statutes: Minnesota Statutes, section 142B.01, subdivision 27, 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. Conclusion: A. Maltreatment: Information was consistent that on July 15, 2025, the AV was left unsupervised in the vestibule for approximately eight minutes which was a violation of Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was not injured, the AV was four years old and alone in the vestibule without staff person knowledge. The door to the facility was locked and the AV the AV was not able to get into the facility. The vestibule entrance from outside was unlocked and unknown community persons had access to it along with residents of the attached apartments. The AV was found by the CP, who had entered the vestibule from the apartment entrance doors. The CP walked the AV out of the vestibule and around the front of the building and into the facility. Given the AV’s preschool age, that the AV was locked out of the facility when left in the vestibule, and a community person (the CP) intervened to return the AV to the facility, the incident represented a substantial risk to the AV’s physical health and safety. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental 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 and/or 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s Supervision Policy, Child Supervision Log, and Risk Reduction Plan. SP1 and SP2 were responsible for the care and supervision of the AV at the time of the incident. Both SP1 and SP2 saw the AV enter the vestibule. Information was inconsistent on who had the attendance sheet and who completed the name to face or head count of the children. SP1 and SP2 each stated that they believed the other staff completed the counts. SP1 said that s/he did not do a count of the children as they entered into the facility and assumed that SP2 and P4 “covered” the end of the line. SP2 said that s/he saw the AV behind the buggy but assumed that P4, who was behind SP2, grabbed the AV. In addition, there was no count of the children at the gym and when the class re-entered the younger preschool classroom. SP1 and SP2 were 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 policies and procedures were adequate but not followed. SP1-SP2 received additional training on supervision of children and name-to-face counts. 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 determined responsible for maltreatment. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. 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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