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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: 1121660-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families 651-539-8268 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) ran away from a staff person (SP) and was without the SP’s supervision in the community. The AV was found by a community person (CP1) and returned to the SP. Date of Incident(s): September 22, 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 October 2, 2025; from documentation at the facility; and through six interviews conducted with three community persons (CP1, CP2, CP3), the AV’s family member (FM), a supervisory staff person (P) and the SP. The facility provided care for children three to five years old while maintaining a trauma-informed and neurodiversity affirming environment. The facility had two “Intensive” classrooms with ratios of one staff person to five children. The facility was located on the east side of a shared office building. To the west of the facility was North Broadway Avenue, a busy, divided, four lane road with a 45 miles per hour speed limit. On the east side of North Broadway Avenue were businesses including the facility and a used car dealership with a service bay. On the west side of North Broadway Avenue was a large church parking lot. Beyond the parking lot was a steep hill, a chain link fence, and residential homes. There were a sidewalk and a frontage road between North Broadway Avenue, the facility and used car dealership. Between the facility and the used car dealership, which was to the north of the facility, was another unknown business and a retaining wall. To the east of each business was a parking lot with cars and a tall, rocky bluff. There was a playground on the north side of the facility. To access the playground, staff persons and children walked out the facility front door and along a sidewalk area that was unfenced. Approximately five feet before the front door were two columns and a push button accessible door access button. Facility documentation showed the AV was four years and 9 months old and enrolled in the Rose Intensive Classroom. The facility’s record for the AV included a release signed by the FM on September 19, 2025, authorizing the facility to obtain the AV’s school records, including special education records, speech and language evaluations, and other records. The facility did not have an Individual Child Care Program Plan for the AV and lacked multiple other required documents from the AV’s file. The FM stated that the AV was diagnosed with autism, was non-verbal, had an Individualized Education Plan (IEP), and was newer to the facility. According to the FM, at the time of the AV’s enrollment at the facility, the facility was made aware that the AV had special needs and had eloped from a previous child care facility. CP1 stated that on September 22, 2025, at approximately 10 a.m., s/he was on the sidewalk near the used car dealership and saw the AV run toward the sidewalk in front of the dealership. CP1 stated the AV continued and ran across all four lanes of North Broadway Avenue. CP1 ran after the AV. The AV ran across the church parking lot, down the hill, and was stopped at a chain link fence when CP1 caught up with him/her. The AV “laughed” and CP1 picked up the AV. CP1 told the AV that s/he could not “run away like that” because s/he could get “hurt,” and the AV responded, “Okay.” A “customer” at the used car lot caught up with them at this time and together, they walked back across North Broadway Avenue to the used car dealership parking lot where they met the SP. There was another customer in the dealership lot, and the SP asked that customer to hold the hands of other children that were with the SP. The SP told CP1 that the AV “got away from us.” The SP took the AV from CP1 and the SP and the children “walked off.” CP2 stated on September 22, 2025, s/he was inside the used car dealership when the AV entered the dealership through open, service bay doors, ran through the showroom and out the dealership front door and into the dealership parking lot. The AV then ran across North Broadway Avenue and across the church parking lot. Another dealership employee, CP3, chased after the AV. CP3 stated that on September 22, 2025, s/he was seated at his/her desk inside the dealership when the AV ran through the service bay, through the showroom and into the parking lot. CP2 ran after the AV but could not catch him/her. The AV then ran across North Broadway Avenue, across a parking lot and was at a fence when CP3 caught up to him/her. CP1 and CP3 walked the AV back to the dealership parking lot. The SP and three other children were at the parking lot and when they gave the AV to the SP, the SP said, “That happens.” The used car dealership provided video footage for September 22, 2025, from a camera pointed into the dealership lot and across North Broadway Avenue. The video was time stamped, did not contain audio and showed that at 10:30 a.m., the AV was at the far end of the lot, near the frontage road. The AV crossed the frontage road, the sidewalk, and then the north bound lanes. After the AV entered the south bound lane, a vehicle drove north. The AV crossed the south bound lanes and as s/he reached the edge of the road, a vehicle travelling south stopped. The AV crossed a parking lot and was out of camera view. Fifty-one seconds later, the SP and three children walked into camera view in the dealership lot. The SP walked with the three children to the end of the lot and left two children with one community person and left one child with the other community person and walked across the frontage road to the sidewalk and the video ended. The FM stated that on October 3, 2025, the P told him/her that on September 22, 2025, the AV, the SP, and other classroom children were outside. When they went into the facility the AV “got away” from the SP. The AV went to a “neighbor’s yard.” The FM stated the “neighbors” were “far” and the AV had to be unsupervised “for a while.” The FM was concerned that the facility did not notify him/her when the incident happened. The following is a summary of the information provided by the P: · The AV was “non-verbal,” and was enrolled in the “Intensive” Rose classroom. · When the AV enrolled at the facility on September 19, 2025, the P did not collect a Parent Questionnaire, where the FM would have indicated any special needs for the AV, and did not collect the AV’s immunization record. The P stated s/he should have told the FM that s/he could not leave the AV at the facility on his/her first day. · Throughout the day on the AV’s first day at the facility, September 19, 2025, from the office, the P saw the AV “escape” the Rose classroom. The P stated that when the AV eloped from the classroom, the AV seemed to think it was a game because the AV smiled when staff persons ran after him/her. · September 22, 2025, was the AV’s second day at the facility. · The P wrote Individual Child Care Program Plans (ICCPPs) for children who had individualized education plans (IEPs). · According to video footage, on September 22, 2025, at approximately 9:47 a.m., the SP and four children, including the AV, entered the playground. At approximately 10:31 a.m., the SP and four children, including the AV, exited the playground. At 10:38 a.m., the SP and four children, including the AV, entered the facility. · After the incident, the SP walked the AV to the P’s office and told the P that when the class was outside, the AV had gotten out of the “fence,” and ran. Another child told the P that s/he saw the AV “go to the left down by the mechanics,” and the mechanics said that the AV “could have been hit on Broadway.” The SP told the P that s/he had to “go catch” the AV and talked with people at the “car” place. The P asked the SP if s/he had the walkie talkie, and the SP told the P that the walkie talkie was with another child who had the backpack. The P stated that s/he “thought” the AV was always within the SP’s sight and/or sound. · The P was unsure if the AV eloped from the fenced playground or if s/he left the SP and other children as they walked to and from the playground. · When transitioning children in the Intensive Classroom to or from the playground, staff persons were trained to walk out “hand in hand,” or the children walked while a staff person carried a child. If/when a child ran, staff persons were trained to “radio” the P “right away.” The SP provided the following information: · On an unknown date at approximately 10:45 a.m., the SP and four children, including the AV, walked from the playground to the facility door. The AV walked on the left side and a “little to the back” of the SP and the SP did not hold any child’s hands. At the push button accessible door access button, the SP placed a backpack, with a walkie-talkie, on another child and a child pushed the button to open the facility door. · Some children walked into the facility and out of the corner of his/her eye, the SP saw the AV “zooming” away. The child with the backpack dropped the backpack, and the SP “screamed” for the children to “stay.” Approximately “five seconds” after the AV ran away, the SP ran after him/her, and the other children followed. One child told the SP that s/he saw the AV go to the left. The SP and the children jumped down the retaining wall ledge and walked to the used car dealership. The SP talked with a dealership employee and was told that “they almost caught” the AV. The SP and the children were in the dealership parking lot, and the SP asked “someone” to help hold the children’s hands. The SP then saw the AV walking back with CP1 and CP3. · The SP and the four children, including the AV, walked back to the facility. As the SP and the children walked past the P’s office, the SP told the P that the AV “got loose and went over Broadway and it was really bad.” The P told the SP that s/he would contact the fire department to “see what more” the facility could do to have more “security.” The SP then walked the children to the classroom and settled. When the children were seated for lunch, the SP was able to leave the classroom and went to the P’s office. The SP told the P that s/he did not have the walkie-talkie, and that the P might want to talk with the dealership employee because they “might have an issue with what happened.” The SP stated s/he asked someone, but did not recall who, if they wanted him/her to write a report on the incident and was told that they would call the FM. · The SP thought from the time the AV ran off to the time the AV was back in the facility was approximately seven minutes. · Prior to October 2, 2025, the SP did not see an ICCPP for the AV. September 22, 2025, was the third day that the SP cared for the AV and before September 22, 2025, the AV had run out of the classroom, down a hallway, and toward the facility office. · When transitioning children from the playground to the classroom, the SP was trained to hold the hands of children that “might run off,” have children walk with the SP and not run ahead, and to make a game of walking from one area to another. The facility provided a one minute and five second video with audio that was not time stamped. The video showed a child outside the P’s office. That child knocked and opened the P’s door and stepped into his/her office with the door open. Another child ran down a hallway past the P’s office. Eight seconds later the SP walked into camera view, carrying the AV in one arm, and holding the hand of another child with the other. The SP stopped at the P’s office door and told the P that the AV “ran” and “made it far.” The SP told the P that as they were “coming in,” another child told the SP that s/he saw the AV go to the “left” down by the “mechanics.” There was unintelligible conversation between the P and the SP and then the SP said, “They will probably call and let you know how bad it was.” The SP then walked down the hallway, and the video ended. The facility’s Staff Policies and Procedures stated that staff persons must provide “active supervision.” When moving from one destination to another, a staff person would be at the beginning of the line, and a staff person would be at the end of the line. If a child went missing and there was only one staff person in the area, that staff person should first call for assistance via the “radio,” and then immediately begin searching for the child. Staff persons might need to adapt to different situations and accommodate needs of children from various backgrounds, abilities, and learning styles. The facility’s Guardian/Parent Policy stated that upon enrollment, family members were required to complete and return required enrollment forms prior to a child’s first day of attendance. An Individual Child Care Program Plan was required within 30 days of enrollment. Facility documentation showed that the P and the SP were each trained on the Reporting of Maltreatment of Minors Act and the facility’s policies including the Staff Policies and Procedures 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. Minnesota Rules, part 9503.0065, subpart 3, states that when a license holder admits a child with special needs, the license holder must ensure that an ICCPP is developed to meet the child’s individual needs. The ICCPP must be in writing and specify methods of implementation and be reviewed and followed by all staff who interact with the child. Minnesota Rules, part 9503.0125, states that at the time of enrollment in the center, the license holder must ensure that a record is maintained on each child, including an ICCPP for each child with special needs. Facility History On October 30, 2024, the facility was issued a Correction Order for failure to develop an ICCPP for a child with a known allergy. The facility submitted a corrective action in response to the Correction Order stating that they created an ICCPP and trained staff on how to respond to the child’s allergy. On July 9, 2025, the facility was issued a Correction Order with two citations for children’s files not containing required information and one citation for failure to have on file a written ICCPP for two children. On August 1, 2025, the facility submitted corrective action in response to the Correction Order stating that within 30 days, all children’s file information would be completed, including ICCPPs for children with special needs. Conclusion: A. Maltreatment Information from the P, the FM, and the facility’s records was consistent that when the AV enrolled at the facility, the P was made aware that the AV had special needs, and the AV was placed in the facility’s “intensive” classroom. The FM said that when the AV was enrolled, the facility was made aware that the AV had eloped from a previous child care facility. According to the P, on the AV’s first day attending the facility, September 19, 2025, the P saw the AV “escape” from his/her classroom and the AV seemed to think it was a game. Information from all sources, including video provided by the facility, video provided by the used car dealership, CP1, CP2, CP3, the P, and the SP, was consistent that on September 22, 2025, at approximately 10:30 a.m., the AV ran away from the SP when the SP was walking the AV and three other children from the playground back into the facility. The AV jumped down a retaining wall ledge, ran behind a local business, entered the used car dealership service bay, ran through the dealership, and out the dealership front door. The AV then crossed the dealership parking lot, a frontage road and sidewalk, and four lanes on North Broadway Avenue when a car needed to stop to prevent from hitting the AV. The AV then crossed a parking lot and ran down a hill where s/he was stopped by a fence. CP1 and CP3 caught up to the AV and walked him/her back to the dealership parking lot where the SP waited. The AV was without the SP’s supervision for an unknown amount of time, which was a violation of the facility’s Staff Policies and Procedures and a violation of Minnesota Statutes 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A. For the following reasons, 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: · Prior to the incident, the facility knew, or should have known, that the AV had known disabilities and displayed a tendency to leave his/her classroom. However, the facility did not develop and implement a strategy to reduce this risk for the AV. · The facility’s practice of a single staff person transitioning multiple children through an unfenced area between the playground and the building did not allow the SP to run after the AV when the AV left the group, as doing so would have left other children unsupervised in unsafe conditions. · While the AV was unsupervised, s/he was exposed to dangers including entering the dealership service bay, parking lots, crossing a busy street, and exposure to unknown community persons. 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. The SP was responsible for the AV’s care at the time of the incident. However, the facility did not develop and implement a strategy to reduce the AV’s known risk of leaving a location without permission. In addition, when the AV ran away from the group, the SP was transitioning children from the playground to the building in accordance with the facility’s policies, procedures, common practices, and his/her training. Given that the SP was with three other children in an unfenced area when the AV ran away from the group, the SP was unable to match the AV’s speed without leaving behind and endangering the other children. Although the SP did not follow the facility’s policy for missing children by calling for help on the radio before pursuing the AV, it was unlikely that doing so would have resulted in substantially faster intervention during the incident. Therefore, the SP’s responsibility was mitigated and the facility was determined responsible for the maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. The AV was not injured a result of the neglect determined in this report. The substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. 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 and procedures were adequate but not followed by the SP (the internal review did not detail what policies or procedures were not followed). The facility noted that to prevent a similar incident from occurring in the future, “When [the AV] is in attendance there will always be two staff during outside time and during transitions.” All staff persons were retrained on the facility’s Supervision Policy and Elopement Policy. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: On October 19, 2026, the license holder was ordered to forfeit a fine of $1,000 as a result of the substantiated maltreatment for which the facility was responsible. In addition, it was determined that facility mandated reporters, including supervisory and administrative staff persons had knowledge of the alleged incident and did not report the incident as required. The license was ordered to forfeit a fine of $200 for failure to report maltreatment. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. On October 19, 2026, the facility was issued a correction order for failing to obtain required information for a child’s file. 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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