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COMMENT DUE DATE:  

March 4, 2013

DATE: 

February 1, 2013

Mitzi Lee, OCCS  (405) 521-2556

Nancy Kelly, OIRP  (405) 522-6703

Dena Thayer, OIRP Programs Administrator  (405) 521-4326

RE:  

APA WF 12-24

It is very important that you provide your comments regarding the DRAFT COPY of policy by the comment due date. Comments are directed to *STO.LegalServices.Policy@okdhs.org

The proposed policy is  Permanent .  This proposal is subject to the Administrative Procedures Act

The proposed policy is permanent and the proposed effective date is July 1, 2013.

CHAPTER 110. LICENSING SERVICES

Subchapter 1. General Provisions

Part 1. Licensing Services – Child Care

OAC 340:110-1-4.1 [AMENDED]

OAC 340:110-1-9.2 through 340:110-1-9.3 [AMENDED]

Part 3. Licensing Services – Residential Care and Agencies

OAC 340:110-1-43.1 [AMENDED]

OAC 340:110-1-47.1 through 340:110-1-47.2 [AMENDED]

(Reference WF 12-24)

SUMMARY:The proposed amendments to Chapter 110, Subchapter 1 amend the rules to:(1) clarify division policy and practice; and (2) assist with the consistent enforcement of licensing requirements as it relates to the use of a form to be completed by facilities when addressing non-compliances with licensing requirements.

SUBSTANTIVE CHANGES:

OAC 340:110-1-4.1 and 340:110-1-43.1 are amended to reflect clarification and purpose of a division form.

OAC 340:110-1-9.2, 340:110-1-9.3, 340:110-1-47.1, and 340:110-1-47.2 are amended to clarify division policy and practice regarding the use of a division form.

LEGAL AUTHORITY:Director of Human Services; Section 162 of Title 56 of the Oklahoma Statutes (56 O.S. § 162); and the Child Care Facility Licensing Act, 10 O.S. § 401.

OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Rule Impact Statement

To:Dena Thayer, Programs Administrator

Policy Management Unit

From:Lesli Blazer

Director of Oklahoma Child Care Services

Date:February 1, 2013

Re:CHAPTER 110. LICENSING SERVICES

Subchapter 1. General Provisions

Part 1. Licensing Services – Child Care

OAC 340:110-1-4.1 [AMENDED]

OAC 340:110-1-9.2 through 340:110-1-9.3 [AMENDED]

Part 3. Licensing Services – Residential Care and Agencies

OAC 340:110-1-43.1 [AMENDED]

OAC 340:110-1-47.1 through 340:110-1-47.2 [AMENDED]

(Reference WF 12-24)

Contact: Mitzi Lee 405-521-2556

A. Brief description of the purpose of the proposed rule:

Purpose.The proposed amendments to Chapter 110, Subchapter 1 amend the rules to:(1) clarify division policy and practice; and (2) assist with the consistent enforcement of licensing requirements as it relates to the use of a form to be completed by facilities when addressing non-compliances with licensing requirements.

Strategic Plan impact.The proposed rules achieve Oklahoma Department of Human Service (OKDHS) goals by clarifying procedures that support and strengthen the family and protect its members, while improving systems and processes to achieve agency goals.

Substantive changes.

OAC 340:110-1-4.1 and 340:110-1-43.1 are amended to reflect clarification and purpose of a division form.

OAC 340:110-1-9.2, 340:110-1-9.3, 340:110-1-47.1, and 340:110-1-47.2 are amended to clarify division policy and practice regarding the use of a division form.

Reasons.The proposed revisions reflect clarifications to division practice and procedure allowing for a consistent enforcement of licensing requirements and division policy and procedures.

Repercussions.If the proposed revisions are not implemented negative repercussions could occur as amendments assist licensing staff in the consistent enforcement of requirements and division policy.

Legal authority.Director of Human Services; Section 162 of Title 56 of the Oklahoma Statutes (56 O.S. § 162); and the Child Care Facility Licensing Act, 10 O.S. § 401.

Permanent approval. Permanent rulemaking approval is requested effective July 1, 2013.

B. A description of the classes of persons who most likely will be affected by the proposed rule, including classes that will bear the costs of the proposed rule, and any information on cost impacts received by the Agency from any private or public entities: The classes of persons most likely to be affected by the proposed rules are licensed child care facilities, parents utilizing licensed child care, children in care at licensed facilities, and child care services licensing staff.The affected classes of persons will bear no costs associated with implementation of the rules.

C. A description of the classes of persons who will benefit from the proposed rule: The classes of persons who will benefit are licensed child care facilities, parents utilizing licensed child care, children in care at licensed facilities, and child care services licensing staff.

D. A description of the probable economic impact of the proposed rule upon the affected classes of persons or political subdivisions, including a listing of all fee changes and, whenever possible, a separate justification for each:The revised rules do not have a known economic impact on the affected entities.There are no fee changes associated with the revised rules as the revisions are to clarify division policy and procedures.

E. The probable costs and benefits to the Agency and to any other agency of the implementation and enforcement of the proposed rule, the source of revenue to be used for implementation and enforcement of the proposed rule and any anticipated effect on state revenues, including a projected net loss or gain in such revenues if it can be projected by the Agency:The amended rules will result in enhanced delivery of services having a positive impact on children, families and licensed facilities as it improves the consistent application of division policy and enforcement of licensing requirements.Training of division staff will be conducted by state office personnel.

F. A determination whether implementation of the proposed rule will have an impact on any political subdivisions or require their cooperation in implementing or enforcing the rule:The proposed rules do not have an economic impact on any political subdivision, nor will the cooperation of any political subdivisions be required in implementation or enforcement of the rules.

G. A determination whether implementation of the proposed rule will have an adverse economic effect on small business as provided by the Oklahoma Small Business Regulatory Flexibility Act:There are no anticipated adverse effects on small business as provided by the Oklahoma Small Business Regulatory Flexibility Act.

H. An explanation of the measures the Agency has taken to minimize compliance costs and a determination whether there are less costly or non-regulatory methods or less intrusive methods for achieving the purpose of the proposed rule:There are no less costly, nonregulatory, or less intrusive methods for complying with state statute.

I. A determination of the effect of the proposed rule on the public health, safety, and environment and, if the proposed rule is designed to reduce significant risks to the public health, safety, and environment, an explanation of the nature of the risk and to what extent the proposed rule will reduce the risk:Implementation of the proposed rules will have a positive impact on the health, safety, and well-being of licensed facilities, families, and children utilizing licensed care.

J. A determination of any detrimental effect on the public health, safety, and environment if the proposed rule is not implemented:Proposed rules allow for the consistent enforcement of licensing requirements and division policy that affects the quality of care received by children in licensed facilities.

K. The date the rule impact statement was prepared and, if modified, the date modified:Prepared December 11, 2012; modified February 1, 2013.

SUBCHAPTER 1. LICENSING SERVICES

PART 1. LICENSING SERVICES – CHILD CARE

340:110-1-4.1. Forms

Revised 7-1-117-1-13

Forms that apply to this Part are described in this Section.

(1) 07LC002T, Staff Summary.Form 07LC002T is used to document compliance with licensing requirements for all staff currently employed by the child care facility.

(2) 07LC003E, Monitoring Report - Child Care Center.Form 07LC003E is used by the licensing staff to document compliance with requirements during a monitoring visit at a child care center and record any other information obtained.

(3) 07LC004E, Request for License - Child Care Facility.Form 07LC004E is used to request a license to operate a child care facility, including a child care center, school-age program, and part-day children's program.

(4) 07LC005E, Transportation Information.Form 07LC005E is used by a child care facility director to document compliance with licensing requirements on transportation.

(5) 07LC006E, Equipment Inventory - Child Care Center.Form 07LC006E is used to document the equipment available and items needed to comply with OKDHS Publication no. 84-08, Licensing Requirements for Child Care Centers.

(6) 07LC007E, Training Documentation.Form 07LC007E is used by child care facilities to document annual training of staff.

(7) 07LC008E, Periodic Monitoring Report - Certification for Care of Children with Disabilities.Form 07LC008E is used by the licensing staff to document ongoing compliance with certification requirements during monitoring visits.

(8) 07LC010E, Monitoring Report - Part-Day Children's Program.Form 07LC010E is used by the licensing staff to document compliance with licensing requirements during a monitoring visit at a part-day children's program and to record any other information obtained.

(9) 07LC012E, Licensing Complaint.Form 07LC012E is used to record a complaint against a child care facility.

(10) 07LC014E, Monitoring Report - Family Child Care Home. Form 07LC014E is used to document compliance with requirements during a monitoring visit to a family child care home and record other information obtained.

(11) 07LC020E, Equipment Inventory - Part-Day Children's Program.Form 07LC020E is used to document the equipment available or needed to comply with Licensing Requirements for Part-Day Children's Programs, no. 95-12, OKDHS Publication.

(12) 07LC021E, Comments and Recommendations Regarding Licensing Requirements.Form 07LC021E is used to make comments and recommendations pertaining to licensing requirements and policy.

(13) 07LC023E, Monitoring Report - School-Age Program.Form 07LC023E is used to document compliance with licensing requirements for school‑age programs during a monitoring visit and record any other information obtained.

(14) 07LC024E, Equipment Inventory - School-Age Program.Form 07LC024E is used to document the equipment available or needed to comply with Licensing Requirements for School-Age Programs, no. 97-10, OKDHS Publication.

(15) 07LC025E, Request for Child Care Center Star Certification.Form 07LC025E is used by a child care center owner or director to request star certification.

(16) 07LC026E, Child Care Center Star Certification Review.Form 07LC026E is used to document compliance with criteria for star certification and to establish a plan to correct violations in a child care center.

(17) 07LC027E, Request for Family Child Care Home Star Certification.Form 07LC027E is used by a family child care home provider to request star certification.

(18) 07LC028E, Family Child Care Home Star Certification Review.Form 07LC028E is used to document ongoing compliance with criteria for star certification and to establish a plan to correct violations in a family child care home.

(19) 07LC037E, Notice to Comply.Form 07LC037E is used by a child care facility to document a plan required plans of correction when there is serious or repeated non-compliance with licensing requirements.

(20) 07LC038E, Child Information.Form 07LC038E is used by the child care facility to record enrollment information for a child.

(21) 07LC041E, Staff Information – Child Care Facility.Form 07LC041E is used to record information regarding child care facility staff persons as required by licensing requirements.

(22) 07LC042E, Request for License – Family Child Care Home and Large Child Care Home.Form 07LC042E is used to make application for license to operate a family child care home or large child care home.

(23) 07LC057E, Physical Plant.Form 07LC057E is used by licensing staff to document the floor plan, including indoor and outdoor square footage and numbers of toilets and sinks.

(24) 07LC061E, Alternative Compliance Request.Form 07LC061E is used by a child care facility to request an alternative method of complying with licensing requirements.

(25) 07LC068E, Licensing Specialist Training Checklist.Form 07LC068E is used by licensing staff to ensure completion of all training requirements, per policy, for new licensing specialists.

(26) 07LC069E, Compliance Review for Child Care Centers.Form 07LC069E is used by child care center directors to verify their knowledge of the licensing requirements.

(27) 07LC070E, Fire Safety Inspection Report for Child Care.Form 07LC070E is used by fire officials for inspection of facilities.

(28) 07LC071E, Licensing Services Waiver Referral.Form 07LC071E is used by licensing staff when submitting a waiver request to State Office.

(29) 07LC072E, Compliance Review for School-Age Programs and Summer Day Camps.Form 07LC072E is used by school-age and summer day camp directors to verify their knowledge of the licensing requirements.

(30) 07LC073E, Compliance Review for Part-Day Children's Programs.Form 07LC073E is used by part-day children's program directors to verify their knowledge of the licensing requirements.

(31) 07LC074E, Request for Extension of Time to Comply.Form 07LC074E is used by child care providers to request an extension of time to comply with Stars criteria.

(32) 07LC075E, Notice of Alternative Compliance.Form 07LC075E is used by licensing staff to notify a facility of an approved request for alternative method of compliance.

(33) 07LC079E, Child Death Report.Form 07LC079E is used by licensing staff in the event of a child death in a child care facility.

(34) 07LC080E, Licensing Services Supplemental Information.Form 07LC080E is used to provide supplemental facility information.

(35) 07LC081E, Licensing Complaint Report Summary.Form 07LC081E is placed in the case record and includes the findings of an investigation in compliance with Section 406 of Title 10 of the Oklahoma Statutes.

(36) 07LC084E, Notice to Parents.Form 07LC084E is posted in child care facilities to inform parents of the requirements for licensing compliance posting and the licensing compliance file.

(37) 07LC085E, Notice of Voluntary Cease Care.Form 07LC085E is used to verify with facilities their agreement to voluntary cease care.

(38) 07LC086E, Staff Information - Family Child Care Home.Form 07LC086E is used to record information regarding family child care home staff persons as required by licensing requirements.

(39) 07LC087E, Waiver Notification.Form 07LC087E is used to inform facilities of a decision regarding a waiver request.

(40) 07LC088E, Notice of Emergency Order.Form 07LC088E is used to notify parents of an immediate closure of their child care facility.

(41) 07LC089E, Child Care Waiver Request.Form 07LC89E is used by a program director to request a waiver for persons a person with a restricted criminal history.

(42) 07LC090E, Waiver Reference.Form 07LC090E is used to obtain references for persons a person with a restricted criminal history.

(43) 07LC091E, Change of Ownership.Form 07LC091E is used by current and prospective owners of facilities to notify licensing of ownership changes.

(44) 07LC092E, Insurance Verification.Form 07LC092E is completed annually to verify liability insurance coverage.

(45) 07LC093E, Insurance Exception Notification.Form 07LC093E is completed and posted at the facility to notify parents that liability insurance coverage is not provided or facility reports they are self-insured.

(46) 07LC095E, Notice Regarding Unlicensed Care.Form 07LC095E is provided to facilities during the investigation of unlicensed care.

(47) 07LC096E, Criminal History Review Request.Form 07LC096E is completed by facilities to request a criminal history review by licensing records office.

(48) 07LC097E, Citation Request.Form 07LC097E is used when requesting assistance of Council on Law Enforcement Education and Training (CLEET)-certified officers.

(49) 07LC098E, District Attorney Referral.Form 07LC098E is used when requesting a district attorney file criminal charges and/or issue an injunction.

(50) 07LC099E, Dual Approval Request for Kinship Placement in a Licensed Family Child Care Home.Form 07LC099E is used for approving acceptance of a foster care placement in a family child care home.

(51) 07LC100E, Emergency Order Request.Form 07LC100E is used by licensing specialist and supervisor when requesting an emergency order.

(52) 07LC101E, Restricted Registry Verification.Form 07LC101E is used by child care facilities and licensing to verify non-registration and registration of individuals recorded on the Child Care Restricted Registry.

(53) 07LC102E, Restricted Registry Notification.Form 07LC102E is used by the licensing records office to notify individuals of potential registration on the Child Care Restricted Registry.

(54) 07LC103E, Restricted Registry Final Notification.Form 07LC103E is used by licensing records office to notify individuals of his or her registration on the Child Care Restricted Registry.

(55) 07LC104E, Restricted Registry Notification to Child Care Facility.Form 07LC104E is used by the licensing records office to notify child care facilities of registration of individuals registered on the Child Care Restricted Registry.

(56) Form 07LC105E, Alternative Compliance Referral.Form 07LC105E, is used by licensing staff to refer an alternative compliance request to State Office personnel.

(57) Form 07LC106E, Criminal History Review Results.Form 07LC106E is used to notify facilities of the results of the criminal history review.

(58) Form 07LC107E, Child Care Restricted Registry Notice.Form 07LC107E is used as additional notification to facility employees and residents of the Child Care Restricted Registry registration process.

340:110-1-9. Case management ITS ONLY

Revised 7-1-127-1-13

(a) Periodic monitoring visits.The Oklahoma Child Care Services (OCCS) licensing staff makes a minimum of three unannounced monitoring visits to facilities that operate a full-year program and two unannounced monitoring visits annually to facilities that operate less than a full year.¢ 1Licensing staff varies the time of monitoring visits to include lunch observation and an evening visit to child care centers with extended hours.¢ 2

(b) Ongoing monitoring.During monitoring visits, the licensing staff observes the entire facility, including outdoor play space and vehicles used for transportation, if available.¢ 3At or subsequent to each visit, licensing staff checks:

(1) compliance with licensing regulations;

(2) records for new staff including staff sheets and compliance with background investigations per OAC 340:110-1-8.1;¢ 4 & 5

(3) staff training records;¢ 6

(4) Oklahoma Department of Human Services (OKDHS) computer checks on applicable persons per OAC 340:110-1-8.1;¢ 7

(5) fire and health inspections within the last 24 months, if applicable; ¢ 8

(6) Form 07LC092E, Insurance Verification, within the last 12 months, or posting of Form 07LC093E, Insurance Exception Notification; and

(7) other documentation requiring renewal.

(c) Technical assistance and consultation.Licensing staff provides:

(1) technical assistance to licensees to assist them in meeting minimum requirements; and

(2) consultation on various aspects of quality child care.

(d) Agreements with tribal licensing programs and other monitoring agencies.OKDHS may enter into a cooperative licensing agreement with a tribal licensing program or other monitoring agency.¢ 9

(e) Equipment inventory.Licensing staff completes the appropriate Equipment Inventory Form 07LC006E, 07LC020E, or 07LC024E, prior to a license being issued.The licensing staff or the facility may complete the appropriate equipment inventory prior to a change in facility class and prior to an increase in licensed capacity in a child care center, part-day children's program, and school-age program.The purpose of the inventory is to document the equipment available and items needed to comply with the equipment requirements.The licensing staff may conduct a complete inventory any time concern exists about the availability of required equipment.¢ 10

(f) Change of address.When a facility moves to a new address, the licensing staff conducts a monitoring visit and completes a monitoring report to verify the new location meets licensing requirements, and obtains an updated application.For child care centers, part-day children's programs, and school-age programs, new fire and health inspections, if applicable, are required.¢ 11When a change of address involves care provided in a location other than the caregiver's primary residence refer to OAC 340:110-1-6(a)(3).

(g) Change in facility name.When there is a change in facility name, licensing staff verifies there is no change in ownership, and documents the change in the case record and database.A new application reflecting the facility name change is completed.¢ 12

(h) Change in director.When there is a change in director, licensing staff:

(1) verifies the new director meets qualifications;

(2) obtains the applicable page of Form 07LC004E, Request for License – Child Care Facility, completed by the new director;

(3) obtains references;

(4) obtains from the director an appropriate, complete Compliance Review Forms 07LC069E, 07LC072E, or 07LC073E, if the director has no previous director experience;

(5) notifies the new director of current employees that have been granted a waiver; and ¢ 13

(6) documents the information on Form 07LC080E, Licensing Services Supplemental Information.

(i) Change in primary caregiver.When there is a change in primary caregiver, licensing staff:

(1) verifies primary caregiver meets qualifications;

(2) obtains the applicable page of Form 07LC004E, Request for License-Child Care Facility, completed by the new primary caregiver;

(3) obtains references;

(4) notifies the new primary caregiver of current employees who have been granted a waiver; and

(5) documents the information on Form 07LC080E.

(j) Change in household.All changes in household members are documented on the monitoring report.Form 07LC096E, Criminal History Review Request, must be submitted prior to a new adult household member residing in the home.When there is a new adult household member in a family child care home or large child care home, the required documentation includes:

(1) the applicable page of Form 07LC004E completed by the new adult household member(s);

(2) background investigations per OAC 340:110-1-8.1; and

(3) an OKDHS computer check.

(k) Change in ownership.When there is a change in ownership or change in form of business organization of a family child care home, child care center, part-day program, or school-age program, typically the case is closed and a new application is obtained.Prior to the issuance of a permit or license, the facility must be in compliance with background investigations per OAC 340:110-1-8.1.A permit may be issued if a monitoring visit without numerous, repeated, or serious non-compliances was conducted at the facility within the past 60 days.A full monitoring visit is conducted within two weeks of change of ownership to verify the new owner is able to meet minimum licensing requirements.¢ 14

(l) Change in facility class.When a facility requests a change in facility class, the procedures contained in this subsection are followed.

(1) The case is closed and a new application is required when a family child care home converts to a child care center, part-day program, or school-age program, or when a child care center, part-day program, or school-age program converts to a family child care home.

(2) Any other request for change in class does not require case closure and documentation includes:¢ 15

(A) a request in writing from the provider;

(B) a new application with updated information;

(C) documentation that the facility meets the requirements for the requested class type;¢ 15

(D) the appropriate equipment inventory, if applicable;

(E) a current approved fire inspection, if applicable;

(F) a current approved health inspection, if applicable; and

(G) database updates to the appropriate class and monitoring frequency plan.¢ 1

(m) Procedure for increasing or decreasing capacity.When a facility requests an increase or decrease in licensed capacity, it is documented on Form 07LC080E, Licensing Services Supplemental Information, and must be approved by the licensing supervisor.If the request to increase capacity is due to additional physical space, the facility must not have a history of numerous, repeated, or serious non-compliance, and must provide:¢ 16

(1) the reason for the increase;

(2) an updated floor plan on Form 07LC057E, Physical Plant, that reflects adequate indoor and outdoor space, toilets, and sinks for the increase and any changes;

(3) fire department approval of any space not previously inspected;

(4) health approval of any additional food preparation space not previously inspected;

(5) an updated equipment inventory reflecting adequate equipment for the increase; and

(6) verification of the number of required master teachers.

(n) Inactive cases.A facility is determined to be in inactive status when care has not been provided for more than 90 days.¢ 17

(1) A facility wanting to remain open after 90 days submits a request in writing including a statement that the owner will notify licensing when care is resumed.Licensing staff verify compliance with requirements prior to resuming care.

(2) The facility is contacted by licensing staff every four months by telephone or letter to update the facility status including new household members per (j) of this Section, or other facility changes.

(3) If the facility is a child care center, part-day, or school-age program voluntary closure is discussed with the owner and an agreement to close is reached if possible.

(4) If care has not been provided for more than 12 consecutive months, licensing staff sends a letter to notify the owner of case closure unless OCCS is notified within 10 days of receipt of letter.

(5) Licensing staff visits the inactive facility at least once a year to verify compliance with licensing requirements until closure is final.¢ 18

(6) If a change of address occurs during the time a facility is in inactive status, a full visit is required to verify compliance and follow change of address per (f) of this Section.

(o) Closure of an inactive family child care home and large child care home.Procedures (1) - (4) are followed when closing an inactive family child care home.

(1) Licensing staff contacts the owner of a family child care home and large child care home during the twelfth month of inactive status to verify case status.

(2) Licensing documents the case status on Form 07LC080E, Licensing Services Supplemental Information, and notifies the owner the case will be closed should care not resume.

(3) If care has not been provided for more than 12 consecutive months, licensing staff sends a letter to notify the owner of case closure unless OCCS is notified within 10 days of receipt of letter.

(4) The family child care home and large child care home is closed and must reapply and be approved for a license prior to resuming care, per OAC 340:110-1-6.

(p) Response to a child death.When notified of death of a child while in child care, licensing staff completes Form 07LC079E, Child Death Report, and forwards it to the statewide licensing coordinator or designee.When notified of a death, the licensing staff visits the facility as soon as possible, unless advised otherwise by law enforcement.¢ 19

(q) Serious incident reports.The licensing supervisor submits to the licensing regional programs manager, county director, and statewide licensing coordinator a report of any serious incident.¢ 20

(r) Self-reported incidents.When a provider self-reports a non‑compliance incident, Form 07LC080E, Licensing Services Supplemental Information, is completed and the data system is updated.A letter to include a copy of Form 07LC080E is provided to the facility.¢ 21

INSTRUCTIONS TO STAFF 340:110-1-9

Revised 7-1-127-1-13

1.Monitoring visits.

(1) Staff safety.Safety concerns regarding facility monitoring are staffed with a supervisor for appropriate action.Appropriate action may include the utilization of a witness and/or coordination with law enforcement officials.

(2) Requirements.After each monitoring visit, the licensing staff enters the monitoring frequency plan that reflects the required number of visits per year on the licensing database.Any changes in the monitoring frequency plan must be reviewed with the supervisor.Examples of the required number of visits include:

(A) one visit per year for inactive child care centers, part-day, or school-age facilities;

(B) two visits per year for part-year programs;

(C) three visits per year for facilities with a history of compliance;

(D) six visits per year for applications, six-month permits, and changes in facility class except a large family child care home changing to a family child care home; and

(E) twelve visits per year for seriously non-compliant facilities.

(3) Frequency of visits.

(A) Facilities that operate part-year require only two visits annually.

(B) Facilities that operate a full-year program, including those that offer only part-time care during the week, require three visits annually.

(C) If the When licensing staff visits a facility between monitoring visits for purposes such as picking up paperwork, consultation on a specific issue, verifying a repair has been made or needed items have been purchased, a full monitoring visit is not required.

(i) The visit may be documented on Form 07LC080E, Licensing Services Supplemental Information.

(ii) This information is entered on the database but the visit is not counted toward the required number of visits.

(iii) If numerous, repeated, or serious non-compliance is observed during this visit, a complete monitoring visit is conducted.

(4) Reduced visits.If caseloads prevent licensing staff from conducting the required number of monitoring visits, the supervisor consults with the staff on case management, and the number of required visits may be reduced if approved by the regional programs manager (RPM).This adjustment is approved and documented in the case record by the supervisor.Required visits to non-problematic licensed facilities may be reduced by one visit per year for no longer than a one-year period.

2.Monitoring visits to:

(1) a center are made between 8 p.m. pm and 10 p.m. pm unless extenuating circumstances exist, such as a complaint regarding a different time period or an unsafe neighborhood.

(2) facilities with limited hours of operation such as weekends or evenings are only made during their hours of operation, unless complaint allegations require other observation times or concerns exist.Varying times of visits are not required.Specific hours of operation are documented in the case record.

3.The licensing Licensing staff:

(1) documents observations and discussions on the appropriate monitoring report, enters the information from the monitoring report onto the licensing database, provides copies of the monitoring report within five working business days to the facility's owner/operator and files the original in the facility's file in the Human Service Center local Oklahoma Department of Human Services (OKDHS) office;

(2) when visiting a family child care home:

(A) is cognizant that it is a private home and demonstrates respect for the family's privacy;

(B) is thorough and asks to be shown throughout the entire house and outdoors;

(C) looks in drawers and closets, flushes toilets, or checks water temperature when concerns exist; and

(D) monitors vehicles annually and when concerns exist.

(3) when visiting a child care center, part-day, or school-age program, monitors vehicles, when available, during routine monitoring visits.

4.Licensing maintains facility staff sheets in the case file for one year after their employment has ended.Staff sheets must be purged for public viewing.Licensing staff verifies documentation of non-registration on the Child Care Restricted Registry on applicable persons per OAC 340:110-1-10.1.

5.Document Documents employee Social Security name changes on 07LC080E and attach attaches it to the staff sheet.If the director's name changes, also notify notifies the Center for Early Childhood Professional Development due to implications with the director credential.

6.Training.Licensing staff checks for one-time and annual training requirements at the time of the annual training review or when concerns exist.Training is verified for center staff and home providers who have had an employment anniversary since the last monitoring visit.The information in (1) through (4) of this Instruction is used for the purpose of determining an employment date.

(1) A family child care home or large home provider uses the original application date for the current license number.

(2) A family child care home or large home assistant caregiver uses his or her employment date.

(3) Child care center employees use their employment date with that organization.When there is a change in location that is not a change in ownership, an employee's employment date does not change.

(4) If there is a break in service or a change in ownership, a new employment year begins.

7.Computer checks and docket searches.

(1) Annual computer checks to identify prior Oklahoma Department of Human Services (OKDHS) involvement with the Oklahoma Department of Human Services (OKDHS) are completed on all adults each person 18 years of age and older, who sign signs Form 07LC004E, Request for License-Child Care Facility, and on the owner owners of a child care center centers, part-day children's program programs, or and school-age program programs.These Individuals are checked on the computer by date of birth and Social Security number.

(2) Annual docket searches of the Oklahoma State Courts Network (OSCN) include both Oklahoma Court Information System (OCIS), non-OCIS counties, and the court clerk in non-reporting counties are completed on all adults who sign the application and the owner and director of child care center, part-day children's program, or school-age program.These are checked by all known names.The court clerk in counties where a person resides or is employed is contacted if they are non-reporting counties.Annual docket searches are completed on each person 18 years of age and older, who signs Form 07LC004E and owners and directors of child care centers, part-day children's programs, and school-age programs.Individuals are searched by all known names.Docket searches include:

(A) Oklahoma State Courts Network (OSCN) for Oklahoma Court Information System (OCIS);

(B) non-OCIS counties; and

(C) court clerk offices in non-reporting counties where the individual resides or is employed.

(3) Review of annual OKDHS computer and OSCN searches are required only from the last date of annual review.

(4) While documentation of the OKDHS computer check and OSCN check search is filed in the confidential section of the facility's case, copies of the checks and searches are not required unless new information is found.All other checks and searches are filed in available for public viewing and meet public inspection requirements per OAC 340:110-1-14.

8.Licensing views on-going fire and health inspections and copies are not required for the case file.If the inspection has licensing violations, document this it is documented as a non-compliance.A copy is only needed if problematic.

9.Cooperative licensing agreement.When there is a cooperative licensing agreement with a tribal licensing program or other monitoring program, the procedures contained listed in (1) through (5) of this Instruction are followed.

(1) After each monitoring visit, the licensing staff sends a copy of the completed monitoring report to the tribal licensing worker or agency representative assigned to the facility.

(2) Reports of monitoring visits conducted by the tribal licensing worker or agency representative are sent to the licensing staff, who enters the visit into the licensing database identifying it as a visit conducted by the tribe or other monitoring agency.The monitoring visits count toward the required number of visits made to the facility.

(A) All tribal visits are considered case history.A minimum of two visits per year must be conducted by OKDHS licensing staff.

(B) An OKDHS licensing monitoring report must be used for case action recommendations.

(3) All information in the licensing file, including confidential information except Child Welfare (CW) Services (CWS) reports, is made available to the tribal licensing worker or agency representative upon request.

(4) The licensing Licensing staff coordinates, when appropriate, with the tribal licensing worker or agency representative to conduct complaint investigations, complaint follow-up, non-compliance follow-up, and office conferences.

(5) The licensing RPM is responsible for evaluating the effectiveness of the agreement and ensuring collaboration.

10.Equipment inventory.The date of the inventory and any needed equipment is documented on the monitoring report.Only the initial inventory of a new facility and a subsequent inventory to increase capacity are filed in the facility's file.

11.Change of address.

(1) If the new address is outside of the licensing staff's area, the case is transferred to the appropriate licensing staff, who conducts the monitoring visit.

(2) When the licensing staff is notified of the address change, the licensing staff advises the owner to also report the address change to Family Support Services Division (FSSD) the Adult and Family Services (AFS), child care liaison.

(3) The new application is for information purposes only.The case is not closed and reopened, and the license number remains the same.

(4) A narrative report that reflects the new address is submitted to the licensing staff's supervisor, the supervisor of the receiving licensing staff, and the FSSD AFS, Child Care Subsidy Section.The address, licensing staff, and supervisor are changed on the licensing database by the receiving licensing staff.Critical information on problematic cases is shared with the receiving licensing staff and supervisor.

(5) The licensing Licensing staff notifies the statewide licensing coordinator of the name change.The statewide licensing coordinator or designee issues a new license to the facility and a copy is sent to the licensing staff.

(6) When a child care center, part-day, or school-age program has a change in of address, current employees do not acquire a new employment date or a new background check.

12.The licensing Licensing staff notifies the statewide licensing coordinator of the name change.The statewide licensing coordinator or designee issues a new license to the facility and a copy is sent to the licensing staff.

13.When requested, directors are provided a copy of the waiver letter that is required to be posted.

14.(a) Changes of ownership are staffed with regional programs managers for appropriate action.

(b) Licensing staff advises the owner that Form 08CC001E, Child Care Provider Contract, will be is canceled when the facility's case is closed.The owner is referred to the FSSD AFS child care liaison to request a new contract so that child care provided to children of is not disrupted for families receiving subsidized child care benefits is not disrupted.

(c) If a family child care home changes business entity, the licensing specialist consults with supervisor to determine if a six month permit is required.

(d) When a change of ownership results in the issuance of a six-month permit, fire and health inspections conducted within the last 12 months are accepted.

(e) When a change of business entity results in the issuance of a license, fire and health inspections conducted within the last 24 months are accepted.

(f) Any new facility construction, addition of square footage not previously included in licensed capacity, or kitchen alterations affecting food service requires a new fire and health inspection inspections.

(g) Copies of previous inspections for situations as specified in (d) and (e) of this Instruction are maintained in the new facility file.

15.Change in class.

(1) Change in class includes a family child care home becoming a large child care home, a child care center becoming a school-age program, or a part-day program becoming a child care center.

(2) If a small home that is currently on a six-month permit requests a change in class to a large family child care home, three monitoring visits must be made after the change and prior to license issuance of a license.

16.Change in capacity.The procedure for increasing or decreasing capacity of a facility is outlined in (1) through (4) of this Instruction.

(1) Increase.When a facility requests an increase in capacity, the licensing staff:

(A) verifies current fire and health inspections and notifies the fire department to determine whether another inspection or further evaluation is required.The contact is documented on Form 07LC080E, Licensing Services Supplemental Information;

(B) ensures that the director completes and submits Form 07LC006E, Equipment Inventory - Child Care Center; 07LC020E, Equipment Inventory - Part-Day Children's Program; or 07LC024E, Equipment Inventory – School-Age Program, that reflects adequate equipment for the increase; and

(C) does not recommend to increase capacity when the facility has numerous, repeated, or serious non-compliance with requirements.When the only serious non-compliance was that the facility exceeded capacity, the request for increase is staffed with RPM for appropriate action.

(2) Decrease.When decreasing capacity, the licensing staff updates the floor plan on Form 07LC057E, Physical Plant, indicating which rooms are available for use by children.

(3) Recommendations to increase or decrease capacity.A recommendation to increase or decrease capacity may be made at any time by submitting a narrative report to the licensing supervisor.

(4) Approval.If change in capacity is approved, the statewide licensing coordinator or designee issues a new license to the facility that reflects reflecting the new capacity.A copy of the license is sent to the licensing staff.

17.Licensing staff notifies the:

(1) appropriate stars outreach specialist via email; and the

(2) contract unit via email at childcarecontracts@okdhs.org regarding the status of inactive care. and provides the following information The email includes:

(1)(A) the reason for inactive status;

(2)(B) the effective date of the inactive status;

(3)(C) the length of time the facility has indicated they anticipate being inactive;

(4)(D) a request contracts for the contract unit to notify Oklahoma Child Care Services (OCCS) of the decision to either cancel the contract or deactivate the point of service machine; and

(5)(3) OCCS staff notifies contracts contract unit via email regarding the date that care was resumed.

18.A full visit is conducted 12 months from the last full visit, not from the time the facility was considered inactive.This visit may be announced to ensure someone is present.

19.Child death.When notified of a death, the licensing staff:

(1) determines and documents what occurred and whether the facility was in compliance at the time of death.Documentation includes:

(A) the number of children and staff present at time of incident;

(B) what supervision was provided during this time;

(C) when the caregiver last checked on the child;

(D) the caregiver's response upon finding the child;

(E) the names of involved staff involved; and

(F) notifies the licensing supervisor, county director, licensing RPM, statewide licensing coordinator, and director of OCCS director of the death; and

(2) considers whether the death is possibly related to sudden infant death syndrome (SIDS) and, if so:

(A) documents:

(i) where the child was sleeping and sleep position;

(ii) the condition of the crib or playpen; and

(iii) observations regarding the bedding, pillows, and other items in the sleeping area;

(B) provides the caregiver the pamphlet OKDHS Publication no. 94-01, SIDS – What Child Care Providers and Other Caregivers Should Know;

(C) notifies the licensing supervisor, county director, licensing RPM, statewide licensing coordinator, and director of OCCS director;

(D) obtains verbal or written verification confirming the cause of death as SIDS; and

(E) notifies the Oklahoma State Department of Health SIDS coordinator, who is available to offer support to the caregiver and family.

20.Serious incident.

(1) Serious incidents include, but are not limited to, incidents:

(A) that result resulting in the serious injury or death of a child, such as a shaken baby, a drowning or near drowning, or a traffic accident resulting in serious injury;

(B) that place a child at a high risk for death or injury, such as a child leaving a facility without the staff's knowledge, a child left at a location away from the facility, a child left unattended in a vehicle, or a child left alone in a facility;

(C) such as fire, flood, or tornado that result in significant damage to a facility; and

(D) where media involvement is anticipated.

(2) A serious incident report includes:

(A) the name and age of the child(ren) seriously injured or killed;

(B) the date and time of the incident;

(C) a description of the injuries to the child(ren) or damage to the facility;

(D) the caregiver's account of the incident;

(E) a summary of contacts made with other agencies involved in the investigation of the incident, such as CW CWS or the police;

(F) any pertinent information regarding the caregiver's history, such as prior CWS involvement with CW or a history of numerous, repeated, or serious non-compliance with licensing requirements; and

(G) the names of involved staff involved.

21.Only owners, directors, staff acting in the role of director, or primary caregivers can self-report.If other facility employees self-report non-compliances, it is the self-reports are considered a complaint complaints.

(1) If a self-reported incident requires an abuse or neglect referral to CWS per OAC 340:110-1-9.2(i) and is accepted for investigation, licensing considers the self-reported incident a complaint.

(1)(2) Form 07LC080E is not maintained in the facility's compliance file; however, the letter is maintained in the facility's compliance file and states:

(A) the date of the report;

(B) the description of the non-compliance;

(C) the facility's plan of correction;

(D) the facility is requested to complete Form 07LC037E, Notice to Comply, if when applicable per OAC 340:110-1-9.3(d)(7); and

(E) states "a self-reported serious non-compliance may be considered when reviewing the case for a negative action or a stars reduction."

(2)(3) The licensing response from Licensing to a self-reported non-compliance, per OAC 340:110-1-9.3, is based on the degree of risk to children, whether the provider could have prevented the non-compliance, and the timeliness and effectiveness of the provider's response.

(3)(4) If When required, a follow-up visit is entered as a monitoring visit on the data system.If When a follow-up phone call is conducted, it is entered in the data system as "other contacts."

340:110-1-9.2. Complaint investigations

Revised 7-1-117-1-13

(a) Legal basis.The Child Care Facilities Licensing Act (Act) [10 O.S. § 406] mandates that the Oklahoma Department of Human Services (OKDHS) conduct a full investigation of a complaint alleging a violation against the Act or any licensing requirement.

(b) Receipt of the complaint.Complaints may be made to licensing in writing, in person, by telephone, or electronically.¢ 1

(c) Complaint information.The licensing Licensing staff obtains as much relevant information as possible from the complainant.¢ 2

(d) Screening complaints.The licensing Licensing staff accepts a complaint for investigation when it alleges:¢ 3

(1) non-compliance with licensing requirements;

(2) operation of an unlicensed facility in violation of the Act; or

(3) abuse or neglect of a child in care.

(e) Complaint risk levels.Risk levels are determined by the licensing staff based upon the degree of harm or danger to children in care.Risk levels are used to ensure that investigations occur in a timely manner and to track types of complaints.

(1) Risk level I complaints.Risk level I complaints indicate a child is in imminent risk of serious physical harm.The level of risk is not influenced by the removal of a child from the facility if other children remain in care.Investigations are initiated immediately or no later than 24 hours after receipt of the complaint by the licensing staff unless awaiting investigation by Child Welfare Services (CW)(CWS) or law enforcement.This does not include weekends and holidays if when the facility is closed.Examples of risk level I complaints include:

(A) alleged physical or sexual abuse;

(B) presence or use of illegal drugs while children are in care;

(C) distribution of drugs;

(D) children left alone in the facility or in a vehicle;

(E) extreme facility temperatures;

(F) an infant placed on the stomach for sleeping;

(G) threatening or impaired behavior of a caregiver;

(H) severe understaffing or over licensed capacity;

(I) unlicensed facility;

(J) violating an Emergency Order;

(K) required staff without current cardio-pulmonary resuscitation and first aid training;

(L) failure to obtain background investigations; or

(M) knowingly permitting access to children by persons identified as restricted or registrants.

(2) Risk level II complaints.Risk level II complaints do not indicate there is imminent risk of harm, but without intervention, a child may not be safe.Investigations are initiated within 15 calendar days of receipt of the complaint by the licensing staff, or sooner depending on the degree of risk, unless advised by CW CWS or law enforcement to delay the investigation.Examples include:

(A) leaving children with an underage staff person;

(B) alleged physical abuse from a staff person no longer working in the facility;

(C) inappropriate discipline where no injury is reported;

(D) broken playground equipment;

(E) injury caused by lack of supervision; or

(F) minor understaffing.

(3) Risk level III complaints.Risk level III complaints do not indicate imminent risk of harm and there are no injuries alleged.Investigations are initiated within 30 calendar days of the date of receipt of the complaint by the licensing staff or immediately if a telephone investigation is appropriate.Examples include:

(A) inadequate meal service;

(B) lack of play equipment;

(C) inappropriate use of television or videos; or

(D) inadequate cleanliness of the facility.

(f) The investigation.The licensing Licensing staff conducts a full investigation, obtaining sufficient information to make a finding.¢ 4

(g) Telephone investigation.With supervisory approval, the licensing staff may investigate a complaint by telephone.The discussion and, if necessary, an agreed-upon plan of correction, is documented on Form 07LC080E, Licensing Services Supplemental Information.A copy is sent to the operator.A complaint may be investigated by telephone only when:

(1) the alleged non-compliance does not place children at risk of harm, for example, the facility did not serve milk one day or children have head lice;

(2) the facility has not had numerous, repeated, or serious non-compliance; and

(3) a monitoring visit has been made in the last three months during which substantial compliance was documented.

(h) Procedure for investigating an allegation of operating an unlicensed facility.When a complaint alleging operation of an unlicensed facility is received, the procedure contained in per OAC 340:110-1-13 is also followed.

(i) Child abuse and neglect complaints.Upon receipt of a complaint alleging abuse or neglect of a child in care, the licensing staff immediately notifies the licensing supervisor and makes a referral to CW CWS.If the allegation involves child abuse or neglect or a report indicating that a child is in imminent risk of serious physical harm, the licensing regional programs manager is also notified.¢ 5

(j) Findings.After the investigation is completed, the licensing staff, in consultation with the licensing supervisor, as appropriate, makes a finding as to whether the complaint is substantiated, unsubstantiated, or ruled out.

(1) Substantiated.A finding of substantiated is made when a weighing of theinformation obtained during the investigation clearly indicates the facility violated any licensing requirement or the Act.

(2) Unsubstantiated.A finding of unsubstantiated is made when the information does not lead to a definite conclusion, for example:

(A) there is insufficient or conflicting information on which to conclude that a violation occurred; or

(B) information needed to make a finding is unavailable.

(3) Ruled out.A finding of ruled out is made when a weighing of the information clearly indicates that there was not a violation of any licensing requirement or the Act.

(k) Documentation of findings.Upon completion of the investigation, the licensing staff:

(1) documents the findings;¢ 6

(2) notifies the provider of the complaint allegations and findings by sending a complaint findings cover letter, Form 07LC081E, Licensing Complaint Report Summary, and if applicable, Form 04CP004E, Child Welfare Investigative Summary Notification to Child Care Licensing Services;

(3) enters the complaint information on the licensing database using complaint key words; and

(4) updates and closes the complaint tracking screen.

(l) Use of Notice to Comply.When a serious complaint allegation has been substantiated, the licensing staff advises the facility to correct the violations immediately and requests that the facility complete Form 07LC037E, Notice to Comply, following the procedure in OAC 340:110-1-9.3(d)(7).

(m) Summary of facts.Facility owners, directors, or primary caregivers may submit a written request for a summary of the facts used to evaluate and determine the licensing complaint findings.¢ 7

(n) Complaint overview.Licensing staff complete an overview of completed complaint investigations on Form 07LC080E.This overview provides a summary of the investigation, how the complaint findings were determined, and is filed in the confidential section.¢ 8

INSTRUCTIONS TO STAFF 340:110-1-9.2

Revised 7-1-127-1-13

1.When the complaint is made in person or by telephone, the licensing staff assists the complainant by:

(1) advising the complainant which complaint allegations represent non-compliance and are enforceable;

(2) responding to the complainant's concerns of the complainant; and

(3) discussing confidentiality, for example, the identity of the complainant is kept confidential unless legal action or a referral to law enforcement officials becomes necessary;

(4) eliciting appropriate information.When subjective terms, such as "drunk" or "crazy" are used, the licensing staff tries to obtain and record specific information on the behavior observed by the complainant;

(5) informing the complainant about what action will be taken, such as the licensing staff will make an unannounced visit or a referral of child abuse will be made to Child Welfare Services (CW)(CWS) for investigation;

(6) requesting a signed, statement from the complainant when serious violations are involved or a negative action may result; and

(7) interviewing the complainant's children if necessary and appropriate.

2.The information requested is recorded on Form 07LC012E, Licensing Complaint, and entered on the complaint tracking system.Allegations Complaint allegations are not released to the public until the findings have been determined.The information requested includes the:

(1) date and time the complaint was received;

(2) facility name of the facility, address, and telephone number;

(3) the complainant's name, address, telephone number, and relationship to the facility, such as employee, parent of a child in care, or neighbor;

(4) the complainant's source of information, for example, personal observation or information from another person; and

(5) specific information regarding the complaint allegations, including:

(A) a description of the circumstances;

(B) name or identity of staff involved;

(C) child(ren) involved or affected by the alleged non-compliance and their age(s);

(D) date(s) and time(s), and place(s) the alleged non-compliance(s) occurred;

(E) place where the alleged non-compliance took place;

(F) names of other persons with relevant information; and

(G)(F) whether the complaint has been discussed with the director.

3.The licensing Licensing staff makes one of the dispositions in this Instruction.

(1) Complaints or concerns that do not meet the criteria in OAC 340:110-1-9.2(d) are discussed with the complainant, and if appropriate, a referral is made to another entity, such as law enforcement, Family Support Services Division Adult and Family Services (AFS), or the Office for Civil Rights.

(2) A complaint alleging violation of licensing requirements or operation of an unlicensed facility is investigated by licensing staff. This information is recorded as a complaint, regardless of the purpose of the caller.The licensing Licensing staff in whose area the facility is located is notified as soon as possible, and Form 07LC012E, Licensing Complaint, is forwarded to the licensing staff.

(3) A complaint alleging child abuse or neglect is immediately referred to Children and Family Services Division (CFSD), CW CWS, with a copy of Form 07LC012E.The referral is documented on the bottom of the form.If an immediate response to the referral is not received, the licensing staff follows up the next working day to obtain a response.

(A) Complaints referred to CW CWS include those that allege harm or threatened harm to a child's safety that occur through non-accidental physical or mental injury, sexual abuse, neglect, or failure or omission to provide protection from harm or threatened harm.

(B) If the licensing staff is unsure whether a complaint meets the criteria for investigation by CW CWS, the complaint is referred to CW CWS and the decision to accept the referral is made by CW CWS staff.

(C) Sex play between children is referred to CW CWS for investigation.Licensing investigates this type of allegation with regard to supervision of children.

(4) When a complaint alleging illegal activity is received, the guidelines contained in (A) through (C)(D) of this paragraph are followed.

(A) A complaint alleging commission of a crime is immediately referred to local law enforcement officials where the facility is located.The referral is followed up in writing, a copy is filed in the facility record, and the licensing supervisor is notified.It is the responsibility of the licensing staff to follow up with local law enforcement officials to determine and document the outcome of the investigation.

(B) If the complaint includes allegations of illegal drug activity, the complaint is referred to local law enforcement, even if when the activity occurred when children were not in care.If the facility has a provider contract, the complaint is also referred to the Oklahoma Department of Human Services (OKDHS) Office of Inspector General (OIG). The referral to OIG is made on Form 19MP001E, Referral Form, and includes date and contact information regarding the referral to local law enforcement.Upon receipt of the referral, OIG contacts the local law enforcement agency to determine whether the agency or OIG will conduct the investigation or whether a joint investigation will be conducted.It is the responsibility of the licensing staff to follow up with OIG to determine and document the outcome of the investigation.

(C) Licensing specialists inform OIG prior to any visits to the facility and consults with them regarding the restrictions of any individuals involved in the allegation.

(D) Complaints alleging the use of illegal drugs during the hours of child care may be addressed with the caregiver after consultation with law enforcement and OIG.Complaints alleging illegal activity of a more serious nature, such as drug trafficking, are not investigated by the licensing staff.

(5) A complaint alleging violation of a person's civil rights is discussed with the complainant.The complainant is referred to the facility in efforts to resolve the issue.If the complaint remains unresolved, licensing staff refer the complainant to the Office for Civil Rights and document the referral on Form 07LC080E, Licensing Services Supplemental Information.

(6) Information in a complaint received from another division within OKDHS or an agency responsible for monitoring child care facilities, such as OIG or the local health or fire department, may be deemed valid if documented in writing by the agency representative.It is licensing staff's responsibility to determine whether the observation is a non-compliance.The facility is advised of the report, requested to complete Form 07LC037E, Notice to Comply, if when applicable, following the procedure in OAC 340:110-1-9.3(d)(7) and given an opportunity to respond.

(7) The licensing supervisor is notified of any complaint:

(A) in which the alleged non-compliance caused or could cause serious harm to a child in care;

(B) when the facility has numerous, repeated, or serious non-compliance with requirements;

(C) when the alleged non-compliance has been addressed previously on Form 07LC037E;

(D) that was referred to CW CWS or law enforcement; or

(E) that is receiving special attention, such as from the media or a legislator.

(8) When a director or owner self reports an allegation made by a parent, licensing staff informs the supervisor and consults with the regional program manager (RPM), when necessary, to determine if potential harm to children warrants an investigation.

4.The investigation generally includes:

(1) a review of the complaint allegations to ensure that investigating staff is thoroughly familiar with the details and specific information, and whenever possible, a review of all appropriate OKDHS records to obtain other preliminary information, as appropriate, prior to making the initial contact;

(2) an unannounced visit to the facility.The purpose of the visit and the nature of the complaint are discussed with the operator.Licensing staff does not identify the complainant;

(3) a review of available records, such as the licensing record, attendance records, injury logs, medical and transportation permission records, child care subsidy records, food program records, or police reports;

(4) interviews with the complainant and complainant's children, if applicable, and others who may have relevant information, such as facility staff or food program employees.An interview:

(A) is conducted when it appears it would provide more complete or accurate information than observation alone;

(B) is generally a face-to-face contact between the licensing staff and the person who may have relevant information.If a person's comments and signature are recorded on Form 07LC080E, the person is given a copy of the report.A copy of the report is not provided to the operator;

(C) is usually conducted in private and with one person at a time.An exception may be made when:

(i) a witness accompanies the licensing staff;

(ii) the parent wishes to be present when the child is interviewed; or

(iii) a person elects to have his or her attorney present;

(D) may be conducted outside the facility if the director is uncooperative, if an on-site interview places the interviewee at risk, or if information must be gathered prior to discussion with the operator.Interviews with persons outside the facility are documented on Form 07LC080E, and the interviewed person is given a copy of the report; and

(E) with a child, takes into consideration the age and verbal ability of the child into consideration, and, preferably, a witness accompanies the licensing staff.

(i) Parental permission prior to interviewing a child in care is not required when investigating a complaint alleging non-compliance with licensing requirements.

(ii) OKDHS Publication no. 05-57, Parent Notification of Child Interview, is provided for parents when a child is interviewed regarding complaint allegations of violations of licensing requirements.Documentation of providing this publication to facilities is made on Form 07LC080E.

(iii) When the licensing staff accompanies CW CWS as part of a joint abuse and neglect investigation, interviews are conducted by the CW CWS worker, per OAC 340:75-3-8.2;

(5) observations at the facility.

(A) If an investigation is associated with a specific time of day, such as early-morning understaffing, the visit to the facility is made at the time the incident is alleged to have occurred.The licensing Licensing staff documents observations by citing the specific conditions observed, for example, the director refused to allow the licensing staff to view the facility's records of staff criminal history investigations or there were nine two 2-year-olds with one staff.

(B) When investigating a complaint at a facility, a complete monitoring visit is not required unless one is due.Staff-child ratios and supervision are checked at each visit and documented on the monitoring report.Should numerous, repeated, and/or serious non-compliance be observed a full monitoring visit is conducted; and

(6) obtaining documentary evidence.Documentary evidence is information that is recorded, such as a CW CWS report, medical and police records, signed statements, or photographs.When documentary evidence is obtained, it is entered in the facility record.

5.Licensing staff procedure.

(1) Whenever possible, the licensing staff accompanies the CW CWS worker on the complaint investigation.However, the licensing staff's role and responsibility is to investigate alleged non-compliance of licensing requirements or the Child Care Facilities Licensing Act.Licensing staff document documents on Form 07LC080E the name, address, and Social Security number of any alleged perpetrator in a CW CWS complaint investigation.

(2) If the CW CWS worker cannot initiate or conclude an investigation within a reasonable period of time, the licensing staff requests approval from the licensing supervisor and consults with the CW CWS supervisor before proceeding with an investigation.A reasonable period of time means the CW CWS investigation of a report that:

(A) a child is in imminent danger or at risk of serious physical harm is initiated within 24 hours; or

(B) does not indicate imminent riskof harm to a child and no injuries are alleged is initiated no later than 15 calendar days after the report is accepted for investigation.

(3) The licensing Licensing staff interviews the alleged victim and his or her parents, usually in their home, following the guidelines outlined in Instructions to Staff # 4(4)(E) of these Instructions.The licensing Licensing staff advises the CW CWS supervisor of the findings, and CW CWS completes its investigation.

(4) If sufficient information is obtained through interviews, observations, or documentary evidence that supports the allegation, and with State Office approval, the licensing staff asks the owner to voluntarily cease care or prohibit the alleged perpetrator from any contact with children pending the outcome of the investigation.The RPM is notified of all situations involving a request for voluntary cease care.The owner is advised of the possibility of an injunction or Emergency Order if the owner refuses and children are considered at imminent risk of harm.

(5) If there is a finding of confirmed or substantiated child abuse or neglect a copy of the report is sent to the RPM and statewide licensing coordinator or designee.

(6) Following completion of the CW CWS investigation, the licensing staff sends a letter to the operator that includes the findings of the investigation and notice of further action that will be taken, if when indicated.

6.After initiating the complaint, licensing staff continue continues to make progress in efforts to complete the investigation within 45 calendar days of receipt.Extended timeframes time frames are staffed with RPM and documented on Form 07LC080E.The licensing Licensing staff enters the findings on the complaint tracking system and completes Form 07LC081E, Licensing Complaint Report Summary, using specific language that is informative to parents.

(1) When a non-compliance other than the original complaint allegation(s) is identified, staff document non-compliances:

(A) on the complaint summary above the plan of correction citation as "additional non-compliances found during the investigation";

(B) on the licensing database in investigative comments; and

(C) in the plan of correction.

(2) When a specific allegation within a key word is unsubstantiated, but a different non-compliance(s) within a key word category is identified, staff unsubstantiate unsubstantiates the specific allegation and document the new non-compliance.Confirm understaffing even if understaffing is in an age group that is different than from the allegation.Document this circumstance as in (1) of this Instruction.

(3) On Form 07LC081E, names or identifying information of the complainant, facility staff, children, and their families are not included.

(4) When a child abuse investigation has been conducted by CW CWS, Form 07LC081E, contains a summary of complaint allegations and findings that does not disclose the identity of the alleged perpetrator or victim, but does allow parents to evaluate the facility.For example, descriptors such as male staff and two 2-year-old female are not used.

(5) Form 07LC081E, the monitoring report, a complaint findings cover letter, and Form 07LC037E, Notice to Comply, if when applicable, are made a part of the open record.Form 07LC012E, Licensing Complaint, and Form 07LC080E, are placed in a confidential file.Interviews with staff, children, collateral witnesses, and complainants are not made part of the public record.

(6) If information regarding a complaint is requested by the public prior to completion of the investigation, the licensing staff explains that information regarding the allegation and findings will be released after the investigation is complete and the provider has been notified in writing of the findings.

7.When requested in writing, the written summary of facts is provided on OCCS letterhead and indicates documents reviewed and the total number of persons interviewed while identifying their relationship to facility such as, parents, staff, children, and collateral, or other agency personnel.Information is provided while protecting confidentiality of all parties.Child Welfare Services reports are identified as an agency document.Supervisor approval is necessary before providing the written summary to the facility.

8.When findings of the complaint are included in the reason for a reduction in star status, the overview is also submitted with the reduction referral.The overview is used for review by supervisors and state office personnel and includes:

(1) number of persons interviewed and their relationship to the facility;

(2) observations regarding the complaint allegations;

(3) documents and records reviewed; and

(4) information used to determine the findings.

340:110-1-9.3. Non-compliance with requirements

Revised 7-1-127-1-13

(a) Documentation of non-compliance.The Oklahoma Child Care Services (OCCS) licensing Licensing staff documents clearly and concisely documents on the monitoring report areas of non-compliance and the discussion with the operator on the monitoring report.¢ 1

(1) A plan of correction, including a specific agreed-upon time period for correction of the non-compliance, is documented for each non-compliance on the monitoring report.If a previous non-compliance was not corrected by the agreed-upon time period, the non-compliance is documented again with a shorter plan of correction date.¢ 2

(2) Immediate correction is required when the non-compliance has a direct impact on the heath health, safety, or well-being of one or more children in care.

(3) The licensing Licensing staff requests that the operator sign the monitoring report, and explains that the operator's signature indicates acknowledgment of information recorded.

(4) If the person in charge refuses to sign, the refusal is documented on the report.

(5) The operator is given a copy of the completed monitoring report.

(b) Referrals to fire and health officials.If non-compliance regarding fire or health requirements places children at risk or remains uncorrected, the licensing staff requests an inspection by a fire, health, or Department of Environmental Quality official.If there is non-compliance regarding smoke detectors, the child care provider is given a copy of the Smoke Detector Law, Section 324.11A of Title 74 of the Oklahoma Statutes.If the non-compliance is not corrected by the third monitoring visit or is frequently repeated, copies of the monitoring reports are sent with a cover letter to the appropriate fire official for enforcement of the law.

(c) Numerous, repeated, and serious non-compliance.

(1) Numerous non-compliance is any monitoring visit with:

(A) five or more items documented as non-compliant on the monitoring report for a family child care home or large child care home;

(B) six or more items documented as non-compliant on the monitoring report for a child care center, part-day children's program, or school-age program with a licensed capacity of less than 60; or

(C) seven or more items for a child care center, part-day children's program, or school-age program with a licensed capacity of 60 or more.¢ 3

(2) Repeated non-compliance is three or more documented incidents of non‑compliance with the same requirement within the last 12 months.For missing immunizations to be considered a repeat non‑compliance, they must be regarding the same child.

(3) Serious non-compliance is a non-compliance with licensing requirements that exposes children to conditions that present an imminent risk of harm.Imminent risk of harm must be assessed based on the age of the child, the amount of time the caregiver was out of compliance, and the caregiver's efforts to mitigate the risk.Serious non-compliances are identified through licensing observations, confirmed complaint investigations, and/or self-reported incidences.Some examples of non-compliance that may be considered as serious are:

(A) staff-child ratio;

(B) supervision of children;

(C) infant sleep environments;¢ 4

(D) prohibited disciplinary actions;

(E) licensed capacity;

(F) use of passenger restraints;

(G) water activities;

(H) pools and other water hazards;

(I) multiple hazards;

(J) weapons;

(K) reporting child abuse;

(L) knowingly permitting access to children by persons identified as restricted or registrants;

(M) failure to obtain background investigations or Child Care Restricted Registry searches;

(N) administering medication to children;

(O) room temperatures;

(P) heat sources and loss of any utility service;

(Q) compliance file and or posting;

(R) cardio-pulmonary resuscitation and first aid training;

(S) liability insurance; and

(T) vehicle liability insurance.

(d) Case management responses to non-compliant facilities.When there is numerous, repeated, or serious non‑compliance, one or more of the actions in (1) through (11)(12) is taken.¢ 5

(1) Technical assistance.Technical assistance is offered along with referrals to consultants or training resources, if necessary, to assist the operator in meeting and maintaining licensing requirements.

(2) Follow-up phone call.Follow-up phone calls are made, and documented on Form 07LC080E, Licensing Services Supplemental Information.A copy of the documentation is mailed to the facility.

(3) Non-compliance letters.A non-compliance letter may be written to the operator.A copy of the non‑compliance letter is sent to the owner or registered agent, if applicable, with a copy of the monitoring report.¢ 6

(4) Return monitoring visit.A return monitoring visit may be made if there is numerous, repeated, or serious non-compliance with licensing requirements or when non-compliance places children at imminent risk of harm. ¢ 7If the non‑compliance is associated with a specific time of day, such as understaffing after school or a lack of early morning supervision, the return visit is made at that approximate time.

(5) Use of witnesses.The licensing Licensing staff may be accompanied by a witness during monitoring visits if the facility has had numerous, repeated, or serious non‑compliances or if denial or revocation of the license is under consideration.The witness may be an Oklahoma Department of Human Services (OKDHS) employee or a representative from the health or fire department.The witness signs the monitoring report in the space provided.

(6) Increased monitoring visits.Licensing staff may increase the frequency of monitoring when there has been numerous, repeated, or serious non‑compliance or when the need for additional technical assistance is indicated.¢ 7

(7) Notice to comply.The licensing Licensing staff provides the facility with Form 07LC037E, Notice to Comply, on which the facility documents the plan of correction.Immediate correction may be required if the non-compliance places the health, safety, or well‑being of one or more children in care at risk.¢ 8

(A) If the plan submitted by the operator is unacceptable to the licensing staff, the licensing staff negotiates and documents a revised plan.

(B) If the Notice to Comply Form 07LC037E is not submitted within the specified time period, the licensing staff contacts the operator and documents the conversation.

(C) If concerns exist or the owner is uncooperative the When non-compliances continue to place children at risk, licensing staff sends a letter stating that failure to complete a Notice to Comply the non-compliances and/or continued failure to correct non-compliances may result in revocation of license, denial of the application, filing of an injunction, or Emergency Order.

(8) Office conference.The licensing Licensing staff may schedule an office conference with the owner of the facility.The licensing supervisor is present at the office conference.The licensing regional programs manager (RPM) is informed of the office conference and may be present, if necessary.

(A) Areas of non-compliance and progress toward meeting the plan(s) of correction are reviewed and technical assistance is offered.

(B) The conference is documented on Form 07LC080E, which is signed by the licensing staff, the operator, and any witnesses present.This documentation includes a list of every person who is present, the purpose of the conference, and verification of correct documentation regarding ownership.

(C) A Notice to Comply Form 07LC037E is completed if one addressing these issues has not been completed recently.

(9) Consent agreement.OKDHS and the owner of the facility owner may enter into a consent agreement whereby the facility owner agrees to specific conditions in lieu of license denial or revocation, per OAC 340:110-1-9.5.

(10) Revocation.The licensing Licensing staff may recommend that the application to become licensed be denied or the license be revoked when numerous, repeated, or serious non-compliance with requirements has been observed and documented or the facility has failed to adequately protect children, per OAC 340:110-1-10.¢ 9

(11) Voluntary cease care.With State Office approval, the owner is asked to voluntarily cease caring for children.The RPM is notified of all situations every situation involving a request for voluntary cease care.

(12) Voluntary closure.With State Office approval, the owner is asked to voluntarily close the facility, per OAC 340:110-1-11.

(e) Case management responses when children are at risk.If the When licensing staff documents non-compliance with requirements or is investigating a complaint that may place the health, safety, or well-being of children at imminent risk of harm, options to consider during consultation with the operator and the licensing supervisor are outlined in this subsection.¢ 10

(1) The operator is asked to immediately correct the non-compliance, for example, the staff person will not work at the facility pending the outcome of an investigation.

(2) The owner is asked to discontinue child care until the non-compliance is corrected or the investigation is complete.

(3) The owner is asked to voluntarily close the facility.

(4) The licensing Licensing staff requests an Emergency Order, per OAC 340:110-1-9.4, when immediate action is needed to protect children in a child care facility.

(5) The owner agrees to enter into a consent agreement whereby the facility owner agrees to specific conditions in lieu of license denial or revocation, per OAC 340:110-1-9.5.

(6) The licensing Licensing staff may recommend that the application be denied or license be revoked when numerous, repeated, or serious non-compliance with requirements has been was observed and documented or the facility has failed to adequately protect children, per OAC 340:110-1-10.

(7) An injunction may be requested when a child care facility is:

(A) unlicensed;

(B) on application status;

(C) licensed;

(D) violating an Emergency Order;

(E) operating during an appeal following revocation or denial and children are at risk; or

(F) violating the notice to cease care following revocation or denial of license.

(f) Notification to supervisor when children are at risk.If during a monitoring visit the licensing staff is concerned that the health, safety, or well-being of children is at imminent risk, the licensing supervisor or OCCS State Office staff is contacted immediately for an appropriate response.¢ 11

(g) Alternative method of compliance.OCCS may approve an alternative method of compliance to a minimum licensing requirement.An alternative method of compliance may be authorized if licensing determines that the alternative method of compliance offers equal protection of health, safety, and well-being to children, meets the basic intent of the requirements for which the alternative compliance was requested, and does not violate statutory requirements.

(1) An applicant or licensee may submit a written request with any supporting documentation on Form 07LC061E, Alternative Compliance Request, to the licensing specialist.A separate request is submitted for each requirement for which an alternative method of compliance is requested.¢ 12

(2) Licensing specialist completes Form 07LC105E, Alternative Compliance Referral, and submits all documentation to the statewide licensing coordinator or designee for authorization.

(3) Approval of an alternative method of compliance does not set a precedent, and is independently evaluated on the merits of each request.

(4) The facility's record of compliance is taken into consideration in determining whether to approve the request.

(5) An alternative method of compliance is not authorized for critical items affecting the health and safety of a child, such as exceeding licensed capacity or staff-child ratios, fire safety violations, or behavior and guidance violations.

(6) Written notice from OCCS, Form 07LC075E, Notice of Alternative Compliance, stating the nature of the exception, is posted with the license.¢ 13

INSTRUCTIONS TO STAFF 340:110-1-9.3

Revised 7-1-127-1-13

1.When documenting non-compliance on the monitoring report, the licensing staff documents what is observed rather than what is needed.For example, the licensing staff writes "milk was not served with lunch" instead of "milk must be served at lunch."

2.If the time period suggested by the operator for correction of non-compliance is unacceptable to the licensing staff, the licensing staff states the expectation and negotiates an acceptable time period.Due dates of corrections are realistic.The following statement may be utilized when facilities are not meeting their plan of correction timeframes:"The facility continues to be in non-compliance without an acceptable plan of correction."Discuss concerns with the regional programs manager or assistant licensing coordinator.

3.Non-compliance.

(1) Each numbered item that has been marked as non-compliant on the monitoring report is counted once when there is more than one non‑compliance included in that item.

(2) A non-compliance may qualify in more than one category in determining numerous, repeated, or serious non-compliance.

(3) If a non-compliance is documented a second time during an agreed‑upon plan of correction for licensing, it is not considered again in determining numerous, repeated, or serious non-compliance.

4.Sleep environment may include:

(1) sleep equipment;

(2) bedding;

(3) infant sleep position; and

(4) infants in cribs with:

(A) bottles; or

(B) soft products.

5.Licensing staff must assess both the number and type of non-compliance observed during monitoring visits or substantiated as a result of a complaint investigation.

(1) The licensing Licensing staff response goes responses go beyond documentation of the non-compliance and plan of correction on the monitoring report for any visit that has numerous, repeated, or serious non-compliance.

(2) The licensing Licensing staff advises the supervisor of the planned response and, if the supervisor disagrees, the case history is staffed and a different or additional response may be utilized.

(3) The response is based on the seriousness of the non-compliance and the demonstrated ability and willingness of the provider to comply.

6.Non-compliance letters are sent within ten working 10 business days, and include the date of the monitoring visit date and areas of non-compliance.If a critical non-compliance remains uncorrected at the next monitoring visit, a letter documenting both visits and a follow-up visit are required.

7.The timing of return visits is determined by the risk level to children, per OAC 340:110-1-9.2(e).A return visit does not routinely result in a change in the monitoring frequency plan.However, if subsequent visits require a follow-up, increased monitoring is discussed with the supervisor.When a return visit is conducted, licensing documents staff child ratios and correction of previous non-compliances on the monitoring report.A full visit is completed if numerous, repeated, and/or serious non-compliances are observed.

8.When Form 07LC037E, Notice to Comply, is completed, the plan of correction on the monitoring report is also completed.If an acceptable Form 07LC037E is completed during a visit, it does not need to be included with the non-compliance letter.Form 07LC037E is may be completed for numerous, or repeated non-compliances; however, completion is necessary for serious:

(1) serious non-compliances;

(2) substantiated complaint allegations; and/or

(3) additional non-compliances found during a complaint investigation.

9.Procedure and documentation for denial or revocation of license.The licensing Licensing staff:

(1) ensures that the non-compliance and a plan of correction are clearly documented on monitoring reports, as well as the facility's action to implement any previous plans of correction;

(2) notes on the monitoring report that failure to correct the non-compliance may result in revocation of the license, denial of application, filing of an injunction, or issuance of an Emergency Order, as applicable; and

(3) conducts monitoring visits at least monthly if children are in care to monitor compliance and the plan(s) of correction.The same witness accompanies the licensing staff on monitoring visits whenever possible.

10.The local resource and referral agency is notified, when the application for licensure is denied, or the license is revoked, or if an Emergency Order is issued, by the statewide licensing coordinator.

11.Situations that might warrant supervisory contact include severe overcapacity, a caregiver is incapacitated or appears under the influence of alcohol or drugs, or children appear to be left alone.

12.Licensing specialist reviews all submitted documentation and may request any additional relevant information.

13.An alternative method of compliance does not replace plans of correction negotiated between licensing staff and providers.Providers are not encouraged to request alternative methods of compliance if the non‑compliance can feasibly be corrected in a reasonable time frame.

PART 3. LICENSING SERVICES – RESIDENTIAL CARE AND AGENCIES

340:110-1-43.1. Forms

Revised 7-1-117-1-13

Forms that apply to this Part are listed in this Subsection.

(1) 07LC005E, Transportation Information.Form 07LC005E is used by a child care facility director to document compliance with licensing requirements on transportation.

(2) 07LC012E, Licensing Complaint.Form 07LC012E is used by licensing staff to record a complaint against a child care facility.

(3) 07LC016E, Recommendation for Licensing or Certification of a Child Care Center.Form 07LC016E is used by licensing staff and supervisors to make recommendations on the licensing or certification of child care facilities.

(4) 07LC021E, Comments and Recommendations Regarding Licensing Requirements.Form 07LC021E is used to make comments and recommendations pertaining to licensing requirements and policy.

(5) 07LC022E, Child-Placing Agency - Foster Care File Review.Form 07LC022E is used by licensing staff to record the agency's compliance or non-compliance with licensing requirements for foster home care.

(6) 07LC037E, Notice to Comply.Form 07LC037E is used by a facility to document a plan required plans of correction when there is serious or repeated non‑compliance with licensing requirements.

(7) 07LC039E, Child Care Staff Health Record.Form 07LC039E is used to document tuberculosis testing and also used by an examining physician to document an employee's physical exam.

(8) 07LC040E, Request for License - Child-Placing Agency, Residential Child Care, and Children's Shelter.Form 07LC040E is used by an agency or residential facility to request application for a child care facility license.

(9) 07LC041E, Staff Information – Child Care Facility.Form 07LC041E is used to record required information regarding child care facility staff.

(10) 07LC043E, Child Placing Agency Compliance Review.Form 07LC043E is used by licensing staff to assess compliance with child-placing agency requirements.

(11) 07LC044E, Adoption Services File Review.Form 07LC044E is used by licensing staff to record the agency's compliance or non-compliance with licensing requirements for placement of children for adoption.

(12) 07LC047E, Agency Certification Report.Form 07LC047E is completed by the child-placing agency staff to certify to the Oklahoma Department of Human Services that each foster home or Independent Living independent living arrangement complies with the Licensing Requirements for Child-Placing Agencies.

(13) 07LC050E, Personnel File Review – Agency and Residential Programs.Form 07LC050E is used by licensing staff to document compliance with personnel record requirements in residential and child-placing agency requirements.

(14) 07LC056E, Compliance Review-Residential Child Care Facility.Form 07LC056E is used by licensing staff to assess compliance with residential requirements.

(15) 07LC058E, Monitoring Report-Residential Child Care Facility.Form 07LC058E is used by licensing staff to document compliance with requirements during a visit to a residential facility and record any other information obtained.

(16) 07LC059E, Residential Child Care Facility - Resident File Review.Form 07LC059E is used by licensing staff as part of the licensing process to document compliance with residential facility requirements.

(17) 07LC060E, Residential Child Care Policy and Records Check.Form 07LC060E is used by licensing staff to document compliance with residential policy and procedure requirements.

(18) 07LC065E, Resident Monitoring Report.Form 07LC065E is used by licensing staff to record the agency's compliance with independent living program licensing requirements for independent living programs.

(19) 07LC071E, Licensing Services Waiver Referral.Form 07LC071E is used by licensing staff when submitting a waiver request to State Office.

(20) 07LC078E, Child-Placing Agency - Record of Foster Home Closure.Form 07LC078E is used by a child-placing agency to report a foster home closure of a foster home.

(21) 07LC079E, Child Death Report.Form 07LC079E is completed by licensing staff to record the death of a child while in child care.

(22) 07LC080E, Licensing Services Supplemental Information.Form 07LC080E is used when additional space for documentation is needed, when a complete monitoring report is not required, to document office and telephone contacts, and to record other information for the licensing record.

(23) 07LC081E, Licensing Complaint Report Summary.Form 07LC081E is placed in the case record and includes the findings of the investigation in compliance with Section 406 of Title 10 of the Oklahoma Statutes.

(24) 07LC087E, Waiver Notification.Form 07LC087E is used to inform facilities of a decision regarding a waiver request.

(25) 07LC089E, Child Care Waiver Request.Form 07LC89E is used by a program director to request a waiver for persons a person with a restricted criminal history.

(26) 07LC090E, Waiver Reference.Form 07LC090E is used to obtain references for persons a person with a restricted criminal history.

(27) 07LC092E, Insurance Verification.Form 07LC092E is completed annually to verify liability insurance coverage.

(28) 07LC095E, Notice Regarding Unlicensed Care.Form 07LC095E is provided to facilities during the investigation of unlicensed care.

(29) 07LC096E, Criminal History Review Request.Form 07LC096E is completed by facilities to request a criminal history review by licensing records office.

(30) 07LC097E, Citation Request.Form 07LC097E is used when requesting assistance of Council on Law Enforcement Education and Training (CLEET)-certified officers.

(31) 07LC098E, District Attorney Referral.Form 07LC098E is used when requesting a DA district attorney file criminal charges and/or issue an injunction.

(32) 07LC101E, Restricted Registry Verification.Form 07LC101E is used by child care facilities and licensing to verify non-registration and registration of individuals recorded on the Child Care Restricted Registry.

(33) 07LC102E, Restricted Registry Notification.Form 07LC102E is used by the licensing records office to notify individuals of potential registration on the Child Care Restricted Registry.

(34) 07LC103E, Restricted Registry Final Notification.Form 07LC103E is used by licensing records office to notify individuals of his or her registration on the Child Care Restricted Registry.

(35) 07LC104E, Restricted Registry Notification to Child Care Facility.Form 07LC104E is used by the licensing records office to notify child care facilities of registration of individuals registered on the Child Care Restricted Registry.

(36) 07LC106E, Criminal History Review Results.Form 07LC106E is used to notify facilities of the results of the criminal history review.

(37) Form 07LC107E, Child Care Restricted Registry Notice.Form 07LC107E is used as additional notification to facility employees of the Child Care Restricted Registry registration process.

340:110-1-47.1. Complaint investigations

Revised 7-1-117-1-13

(a) Legal basis.The Child Care Facilities Licensing Act (Act), Sections 401 et seq. of Title 10 of the Oklahoma Statutes, mandates that the Oklahoma Department of Human Services (OKDHS) conduct a full investigation of a complaint alleging a violation against the Act or any licensing requirement.

(b) Receipt of the complaint.Complaints may be made to Licensing Services, in writing, in person, by telephone, or electronically.¢ 1

(c) Complaint information.The licensing Licensing staff obtains as much relevant information as possible from the complainant.¢ 2

(d) Screening complaints.The licensing Licensing staff accepts a complaint for investigation when it alleges:

(1) non-compliance with licensing requirements;

(2) operation of an unlicensed facility in violation of the Act; or

(3) abuse or neglect of a child in care.

(e) Disposition of complaints.Upon receipt of a complaint, the licensing staff determines a disposition, as described in this subsection.

(1) A complaint that does not meet the criteria in (d) is discussed with the complainant, and, if when appropriate, a referral is made to another entity, such as law enforcement, the Office of Juvenile Affairs, Office of Client Advocacy (OCA), OKDHS Children and Family Services Division Child Welfare Services, or OKDHS Office for Civil Rights.

(2) A complaint alleging violation of licensing requirements or operation of an unlicensed facility is investigated by Licensing Services.¢ 3

(3) A complaint alleging child abuse or neglect is immediately referred to OCA with a copy of Form 07LC012E, Licensing Complaint.¢ 4If When an immediate response to the referral is not received, the licensing staff follows up the next working business day to obtain a response.

(4) When a complaint alleges commission of a crime, including illegal drug activity in the child care facility, it is immediately referred to Office of Inspector General (OIG) and local law enforcement where the facility is located.

(A) The referral is followed up Referral follow ups are documented in writing; a copy is filed in the facility record; and the programs manager is notified.

(B) It is the responsibility of the licensing staff to follow up with local law enforcement officials to determine and document the outcome of the investigation.

(C) A referral to OIG is documented on Form 19MP001E, Referral Form.¢ 5

(5) A complaint received from another division within OKDHS or an agency responsible for monitoring residential child care facilities or child-placing agencies, such as the Oklahoma Commission on Children and Youth (OCCY), OCA, or the local health or fire department, is deemed valid if when documented in writing by the agency representative.Licensing staff determines whether the observation is a non-compliance.The facility is advised of the report and given an opportunity to respond.

(6) The programs manager is notified of any complaint:

(A) in which the alleged non-compliance caused or could cause imminent risk of harm to a child in care;

(B) when the facility has numerous, repeated, or serious non-compliance with requirements;

(C) when the alleged non-compliance has been was addressed in a previous Form 07LC037E, Notice to Comply;

(D) that was referred to OCA or law enforcement; or

(E) that is receiving special attention, such as from the media or a legislator.

(f) Complaint risk levels.Risk levels are determined by the licensing staff based upon the degree of harm or danger to children in care.Risk levels are used to ensure that investigations occur in a timely manner and to track types of complaints.

(1) Risk level I complaints.Risk level I complaints indicate a child is in imminent danger of serious physical injury.The level of risk is not influenced by the removal of a child from the facility if other children remain in care.Investigations are initiated immediately or no later than 24 hours after receipt of the complaint by the licensing staff unless awaiting investigation by OCA or law enforcement.Examples of risk level I complaints include:

(A) alleged physical or sexual abuse;

(B) presence or use of illegal drugs while children are in care;

(C) distribution of drugs;

(D) children left alone in the facility or in a vehicle;

(E) extreme facility temperatures;

(F) an infant placed on the stomach for sleeping;

(G) threatening or impaired behavior of a caregiver;

(H) severe understaffing or over licensed capacity;

(I) unlicensed facility;

(J) violating an Emergency Order;

(K) required staff without current cardio-pulmonary resuscitation and first aid training;

(L) failure to obtain background investigations; or

(M) knowingly permitting access to children by persons identified as restricted or registrants.

(2) Risk level II complaints.Risk level II complaints do not indicate there is imminent danger of injury, but without intervention a child may not be safe.Investigations are initiated within 15 calendar days of receipt of the complaint by the licensing staff, or sooner, depending on the degree of risk, unless advised by OCA or law enforcement to delay the investigation.Examples of risk level II complaints include:

(A) leaving children with an underage staff person;

(B) alleged physical abuse from a staff person no longer working in the facility;

(C) inappropriate discipline where no injury is reported;

(D) broken playground equipment;

(E) injury caused by lack of supervision; or

(F) minor understaffing.

(3) Risk level III complaints.Risk level III complaints do not indicate imminent danger and there are no injuries alleged.Investigations are initiated within 30 calendar days of the date of receipt of the complaint by the licensing staff or immediately if a telephone investigation is appropriate.Examples of risk level III complaints include:

(A) inadequate meal service;

(B) inappropriate use of television or videos; or

(C) inadequate cleanliness of the facility.

(g) The investigation.The licensing Licensing staff conducts a full investigation, obtaining sufficient information to make a finding.¢ 6

(h) Telephone investigation.With supervisory approval, the licensing staff may investigate a complaint by telephone.The discussion and, if when necessary, an agreed-upon plan of correction is are documented on Form 07LC080E, Licensing Services Supplemental Information.A copy is sent to the operator.A complaint may be investigated by telephone only if when:

(1) the alleged non-compliance does not place children at risk of harm, for example, the facility did not serve milk one day or children have head lice;

(2) the facility has not had numerous, repeated, or serious non-compliance; and

(3) a monitoring visit has been made in the last three months during which substantial compliance was documented.

(i) Procedure for investigating allegations of operating an unlicensed facility.When allegations of operating an unlicensed facility are investigated, the procedures contained in per OAC 340:110-1-54.1 are also followed.

(j) Child abuse and neglect complaints.Upon receipt of a complaint alleging abuse or neglect of a child in care, the licensing staff immediately notifies the programs manager and makes a referral to the Office of Client Advocacy.

(k) Findings.After the investigation is completed, the licensing staff, in consultation with the programs manager, as appropriate, makes a finding as to whether the complaint is substantiated, unsubstantiated, or ruled out.

(1) Substantiated.A finding of substantiated is made when a weighing of the information obtained during the investigation clearly indicates that the facility violated a licensing requirement or the Act.

(2) Unsubstantiated.A finding of unsubstantiated is made when the information does not lead to a definite conclusion, for example:

(A) there is insufficient or conflicting information on which to conclude that a violation occurred; or

(B) information required to make a finding is unavailable.

(3) Ruled out.A finding of ruled out is made when a weighing of the information clearly indicates there was not a violation of a licensing requirement or the Act.¢ 7

(l) Documentation of findings.Upon completion of the investigation, the licensing staff documents the complaint allegations, findings, notifies the provider in writing, and enters the complaint information on the licensing database using complaint key words.¢ 7

(m) Notice to Comply.When a serious complaint allegation is substantiated, the licensing staff advises the facility to correct the violations immediately, using Form 07LC037E, Notice to Comply, following procedure per OAC 340:110-1-47.2(c)(7).The facility must complete a plan of correction.

(n) Summary of facts.Facility or agency owners or program directors may submit a written request for a summary of the facts used to evaluate and determine the licensing complaint findings.¢ 8

(o) Complaint overview.Licensing staff provide complete an overview of completed complaint investigations on Form 07LC080E.This overview provides a summary overview of the investigation, how the complaint findings were determined, and is filed in the confidential section.¢ 9

INSTRUCTIONS TO STAFF 340:110-1-47.1

Revised 7-1-127-1-13

1.When the complaint is made in person or by telephone, the licensing staff assists the complainant by:

(1) advising the complainant as to which allegations represent non-compliance and are enforceable;

(2) responding to the complainant's concerns of the complainant; and

(3) discussing confidentiality.For example, the identity of the complainant is kept confidential unless legal action or a referral to law enforcement officials becomes necessary;

(4) eliciting appropriate information.When subjective term terms, such as "drunk" or "crazy" are used, the licensing staff attempts to obtain and record specific information on the behavior observed by the complainant;

(5) informing the complainant about what action will be taken, such as the licensing staff will make an unannounced visit or a referral of child abuse will be made to Office of Client Advocacy (OCA) for investigation; and

(6) requesting a signed, statement from the complainant when serious violations are involved or a negative action may result.

2.The information requested is recorded on Form 07LC012E, Licensing Complaint, and entered into the database system complaint tracking system.The information requested includes the:

(1) date and time the complaint was received;

(2) facility name of the facility, address, and telephone number;

(3) the complainant's name, address, telephone number, and relationship to the facility, such as employee, parent of a child in care, or neighbor;

(4) the complainant's source of information; for example, personal observation or information from another person; and

(5) specific information regarding the complaint allegations, including:

(A) a description of the circumstances;

(B) name or identity of staff involved;

(C) child(ren) involved or affected by the alleged non-compliance and the child(ren)'s their age(s);

(D) date(s), time(s), and place(s) the alleged non-compliance(s) occurred;

(E) names of other persons with relevant information; and

(F) whether the complaint has been discussed with the facility director.

3.This information is recorded as a complaint, regardless of the purpose of the caller.The licensing Licensing staff in whose area the facility is located is notified as soon as possible, and Form 07LC012E, Licensing Complaint, is forwarded to the licensing staff.

4.The referral is documented on the bottom of Form 07LC012E, Licensing Complaint.Complaints referred to OCA include those that allege harm or threatened harm to a child that occurs through non-accidental physical or mental injury, sexual abuse, neglect, or failure or omission to provide protection from harm or threatened harm.

(1) If the licensing staff is unsure whether a complaint meets the criteria for OCA investigation by OCA, the complaint is referred to OCA and the decision whether to accept the referral is made by OCA staff.

(2) Sex play between children is referred to OCA for investigation.Licensing investigates this type of allegation with regard to supervision of the children.

5.It is the responsibility of the licensing staff to follow up with law enforcement and OIG to determine and document the investigation outcome of the investigation.Licensing specialists inform OIG prior to any visits to the facility.

6.(a) The investigation includes:

(1) a review of the complaint allegations to ensure that investigating staff is thoroughly familiar with the details and specific information, and, whenever possible, a review of all appropriate agency records to obtain other preliminary information as appropriate prior to making the initial contact;

(2) an unannounced visit to the facility.The purpose of the visit and the nature of the complaint are discussed with the operator. The licensing Licensing staff does not identify the complainant;

(3) a review of available records, such as the licensing record, children's files, restraint and injury logs, medical and transportation records, food program records, and police reports;

(4) interviews with the complainant and residents of the facility, if applicable, and others who may have relevant information, such as facility staff.The interview:

(A) is conducted when it appears it would provide more complete or accurate information than observation alone;

(B) is usually a face-to-face contact between the licensing staff and a person who may have relevant information.If a person's comments and signature are recorded on Form 07LC080E, Licensing Services Supplemental Information, he or she is given a copy of the report.A copy of the report is not provided to the operator;

(C) is usually conducted in private and with one person at a time.An exception may be made when a witness accompanies the licensing staff, a parent wishes to be present when his or her child is interviewed, or a person elects to have his or her attorney present;

(D) may be conducted outside the facility if the director is uncooperative, if an on-site interview places the interviewee at risk, or if information is to be gathered prior to discussion with the operator.Interviews with persons outside the facility are documented on Form 07LC080E, and the person interviewed is given a copy of the report;

(E) when with a child, takes into consideration the age and verbal ability of the child into consideration.It is preferable that the licensing staff is accompanied by a witness.Parental permission prior to interviewing a child in care is not required when investigating a complaint alleging non-compliance with licensing requirements;

(5) observations at the facility.

(A) When an investigation is associated with a specific time of day, for example, early morning understaffing, the visit to the facility is made at the time the incident is alleged to have occurred.The licensing Licensing staff documents observations by citing the specific conditions observed; for example, the director refused to allow the licensing staff to view the facility's records of staff criminal history investigations or there were 16 residents monitored by one staff.

(B) When investigating a complaint at a facility that is time-consuming, stressful, or involves OCA or other auditing entities, or if a full monitoring visit was made within the last month to a facility with a record of compliance, a complete monitoring visit is not required.Staff-child ratios and supervision are documented on each visit on the monitoring report.Should numerous, repeated, and/or serious non-compliance be observed a full monitoring visit is conducted.The licensing Licensing staff documents compliance with those areas relating to the allegation; and

(6) documentary evidence, which is entered in the facility record.Documentary evidence is information that has been was recorded, such as an Oklahoma Commission on Children and Youth report, medical and police records, signed statement, or photographs.

(b) If sufficient information is obtained through interviews, observations, or documentary evidence that supports an allegation that children are at risk of harm, the licensing staff requests that the owner voluntarily cease care or prohibit the alleged perpetrator from having any contact with children pending the investigation outcome of the investigation.The programs manager is notified of all situations involving a request for voluntary cease care.The owner is advised of the possibility of an injunction or Emergency Order if he or she refuses and children are considered at risk of harm.

(c) Following completion of the investigation, the licensing staff sends a letter to the operator that includes the investigation findings of the investigation and notice of further action that will be taken, if when indicated.

7.After initiating the complaint, licensing staff continue continues to make progress in efforts to complete the investigation within 45 calendar days of receipt.Extended timeframes time frames are staffed with the programs manger and documented on Form 07LC080E.The licensing Licensing staff enters the findings on the data base and completes Form 07LC081E, Licensing Complaint Report Summary, using specific language that will be is informative to anyone who may review the file.

(1) When a non-compliance other than the original complaint allegation(s) is identified, staff document documents non-compliances:

(A) on the complaint summary above the plan of correction citation as "additional non-compliances found during the investigation"; and

(B) on the licensing database in investigative comments; and

(C) in the plan of correction.

(2) When a specific allegation within a key word is unsubstantiated, but a different non-compliance(s) within a key word category is identified, staff unsubstantiate unsubstantiates the specific allegation and document the new non-compliance.Confirm understaffing even if understaffing is in an age group different than from the allegation.Document this circumstance as in paragraph (1) of this Instruction.

(3) Names or identifying information of the complainant, children, and their families are not included on Form 07LC081E.When OCA is not involved, names of staff may be used in complaint findings regarding non-compliance with licensing requirements.When a child care provider is identified on Form 07LC081E, it is even more critical to have strong evidence before substantiating the complaint.

(4) When a child abuse investigation has been was conducted by OCA, Form 07LC081E contains a summary of complaint allegations and findings that does not disclose the identity of the alleged perpetrator or victim, but does allow persons who are interested to valuate evaluate the facility.

(5) Form 07LC081E, is made a part of the open record.Form 07LC012E, Licensing Complaint, is placed in a confidential file.If the complaint allegations and findings have not been given to the provider in writing, a letter is sent to the provider.Interviews with staff, children, collateral witnesses, and complainants are not made part of the public record.

(6) If When information regarding a complaint is requested by the public prior to completion of the investigation, the licensing staff explains that information regarding the allegation and findings will be released after the investigation is complete.

8.When requested in writing, a summary of facts is provided on division OCCS letterhead and indicates documents reviewed and the total number of persons interviewed while identifying the relationship to facility such as, parents, staff, children, and collateral or other agency personnel.Information is provided while protecting confidentiality of all parties.Programs manager approval is necessary before providing the written summary to the facility.

9.The overview is a summary of the investigation and used for review by supervisors and state office personnel and includes:

(1) number of persons interviewed and their relationship to the facility;

(2) observations regarding the complaint allegations;

(3) documents and records reviewed; and

(4) information used to determine the findings.

340:110-1-47.2. Non-compliance with requirements

Revised 7-1-127-1-13

(a) Documentation of non-compliance.The licensing Licensing staff documents clearly and concisely on the monitoring report areas of non-compliance and the discussion with the operator on the monitoring report.¢ 1

(1) A plan of correction, including an agreed-upon time period for correction of the non-compliance, is documented on the monitoring report for each non-compliance or documentation indicates a plan of correction will be submitted by the executive or program director.If a previous non-compliance was not corrected by the agreed-upon time period, the non-compliance is documented again with a shorter plan of correction date.¢ 2

(2) Immediate correction is required when the non-compliance has a direct impact on the health, safety, or well-being of a child(ren) in care.

(3) The licensing Licensing staff requests that the operator sign the monitoring report, explaining that the operator's signature indicates acknowledgment of information recorded.

(4) If When the person in charge refuses to sign, the refusal is documented on the report.

(5) The operator is given a copy of the completed monitoring report.

(b) Referrals to fire and health officials.If When non-compliance regarding fire or health requirements places children at risk of harm or remains uncorrected, the licensing staff requests an inspection by a fire, health, or Oklahoma Department of Environmental Quality (ODEQ) official.

(c) Case management responses to non-compliant facilities.The responses in this subsection may be used when there is repeated, numerous, or serious non‑compliance.¢ 3

(1) Technical assistance.Technical assistance is offered along with referrals to consultants or training resources, if when necessary, to assist the operator in meeting and maintaining licensing requirements.

(2) Follow-up phone call.Phone calls are documented on Form 07LC080E, Licensing Services Supplemental Information, and a copy is mailed to the facility.

(3) Non-compliance letter.A non-compliance letter may be written to the operator.The licensing Licensing staff sends a copy of the monitoring report and non-compliance letter to the governing board or owner, if when applicable.¢ 4

(4) Return monitoring visit.A return monitoring visit may be made if there is repeated, numerous, or serious non-compliance with licensing requirements or when non-compliance places children at imminent risk of harm.If the non‑compliance is associated with a specific time of day, such as understaffing after school or a lack of early morning supervision, the return visit is made at that approximate time.¢ 5

(5) Use of witnesses.The licensing Licensing staff may be accompanied by a witness during monitoring visits if the facility has had numerous, repeated, or serious non-compliances or if license denial or revocation of the license is being considered.The witness may be an Oklahoma Department of Human Services (OKDHS) employee or a representative from the health or fire department.The witness signs the monitoring report in the space provided.

(6) Increased monitoring visits. Licensing staff may increase the frequency of monitoring when there has been numerous, repeated, or serious non-compliance or when the need for additional technical assistance is indicated.

(7) Notice to comply.The licensing Licensing staff provides the facility with Form 07LC037E, Notice to Comply, on which the facility documents the plan of correction.Immediate correction may be required if when the non-compliance places the health, safety, or well-being of a child(ren) in care at risk.¢ 6

(A) If when the plan submitted by the operator is unacceptable to the licensing staff, the staff negotiates and documents a revised plan.

(B) If the operator does not submit the response to Form 07LC037E within the specified time period, the licensing staff contacts the operator and documents the conversation.If concerns exist or the owner is uncooperative, the licensing staff sends a letter stating that failure to complete Form 07LC037E may result in revocation of license, denial of the application, the filing of an injunction, or Emergency Order.

(C) When non-compliances continue to place children at risk, licensing staff sends a letter stating non-compliances and/or continued failure to correct non-compliances may result in revocation of license, denial of the application, filing of an injunction, or Emergency Order.

(8) Office conference.The licensing Licensing staff may schedule an office conference with the owner of the facility.The programs manager is present at the office conference.Areas of non-compliance and progress toward meeting the plan(s) of correction are reviewed and technical assistance is offered.The conference is documented on Form 07LC080E, which is and signed by the licensing staff, the operator, and any witnesses present.This documentation includes a list of the persons present, the purpose of the conference, and verification of correct documentation regarding ownership.Form 07LC037E is completed if one addressing these issues has not been completed recently.

(9) Consent agreement.OKDHS and the owner of the facility owner may enter into a consent agreement whereby the facility owner agrees to specific conditions in lieu of license denial or revocation.

(10) Revocation.The licensing Licensing staff recommends that may recommend the application for licensure be denied or the license revoked when numerous, repeated, or serious non-compliance with requirements has been observed and documented or the facility has failed to adequately protect children.¢ 67

(11) Voluntary cease care.With State Office approval, the owner is asked to voluntarily cease caring for children.The programs manager is notified of all situations every situation involving a request for voluntary cease care.

(12) Voluntary closure.The owner is asked to voluntarily close the facility.¢ 78

(d) Case management responses when children are at risk.If the When licensing staff documents non-compliance with requirements or is investigating a complaint that children may be at imminent risk of harm, options to consider during consultation with the operator and the programs manager are outlined in this subsection.

(1) The operator is asked to immediately correct the non-compliance; for example, the staff person will not work at the facility pending the outcome of an investigation.

(2) The owner is asked to voluntarily close the facility.

(3) The licensing Licensing staff requests an Emergency Order when immediate action is needed to protect children in a child care facility that is on permit, licensed, on notice of revocation or denial, or operating during an appeal following revocation or denial.

(4) The owner agrees to enter into a consent agreement whereby the facility owner agrees to specific conditions in lieu of license denial or revocation.

(5) The licensing Licensing staff recommends that may recommend the license be denied or revoked when numerous, repeated, or serious non-compliance with requirements has been was observed and documented or the facility has failed to adequately protect children.

(6) An injunction may be requested when the residential facility or child-placing agency is:

(A) unlicensed;

(B) on application status;

(C) licensed;

(D) violating an Emergency Order;

(E) operating during an appeal following revocation or denial and children are at risk of harm; or

(F) violating the notice to cease care following denial or revocation of license.

INSTRUCTIONS TO STAFF 340:110-1-47.2

Revised 7-1-117-1-13

1.When documenting non-compliance on the monitoring report, the licensing staff:

(1) documents what is observed rather than what is needed.For example, the licensing staff writes "milk was not served with lunch" instead of "milk must be served at lunch";

(2) discusses areas of non-compliance with the operator and documents the discussion in writing on the monitoring report;

(3) provides a copy of the monitoring report to the operator and governing board or owner, as applicable; and

(4) if when the person in charge refuses to sign the monitoring report, documents the refusal on the report.

2.Plan of correction.

(1) If when the time period suggested by the operator for correction of non-compliance is unacceptable to the licensing staff, the licensing staff states his or her expectation and negotiates an acceptable time period.Due dates of corrections should be realistic.The following statement may be utilized when facilities are not meeting their plan of correction timeframes:"The facility continues to be in non-compliance without an acceptable plan of correction."Discuss any concerns with the program programs manager.

(2) The plan of correction may include an agreement by the administrator or director to specific conditions, such as agreeing to restrict a person convicted of child abuse from the premises, or agreeing not to allow certain staff to transport children because of a prior conviction for driving under the influence (DUI).The agreement:

(A) is placed in a prominent location in the facility's file, such as stapled inside the front cover, so it is readily seen by anyone reviewing the case record; and

(B) includes the conditions that must be complied with, but does not include confidential information; for example, the caregiver has three DUI convictions or the person restricted from the premises has a child abuse conviction.

3.Licensing staff assesses both the number and type of non-compliance observed during monitoring visits or substantiated as a result of a complaint investigation.Response is based on the seriousness of the non-compliance and the demonstrated ability and willingness of the provider to comply.

(1) The licensing Licensing staff response goes beyond documentation of the non-compliance and a plan of correction on the monitoring report when a monitoring visit involves:

(A) five or more areas of non-compliance;

(B) areas of non-compliance that have been were repeated three or more times during a 12-month period; or

(C) non-compliance that is serious or places children in danger.

(2) The licensing Licensing staff advises the programs manager of the planned response and, if when the supervisor disagrees, the case history is staffed and a different or additional response may be utilized.

4.A Licensing staff sends a non-compliance letter is sent by licensing staff within ten working 10 business days, and includes the date of the monitoring visit date and the area(s) of non-compliance.If When a critical non-compliance remains uncorrected at the next monitoring visit, a letter documenting both visits and a follow-up visit are required.

5.The timing of a return visit is determined by the risk level to children.A return visit does not routinely result in a change in the monitoring frequency plan.If When subsequent visits require a follow-up, increased monitoring is discussed with the programs manager.When a return visit is conducted, licensing documents staff child ratios and correction of previous non-compliance on the monitoring report.A full visit is completed if numerous, repeated, and/or serious non-compliances are observed.

6.When Form 07LC037E, Notice to Comply, is completed, the plan of correction on the monitoring report is also completed.When an acceptable Form 07LC037E is completed during a visit, it does not need to be included with the non-compliance letter.Form 07LC037E may be completed for numerous or repeated non-compliances; however, completion is necessary for:

(1) serious non-compliances;

(2) substantiated complaint allegations; and/or

(3) additional non-compliances found during a complaint investigation.

67.Procedure and documentation for denial or revocation of license.

(1) The licensing Licensing staff ensures that the non-compliance and a plan of correction are clearly documented on the monitoring report, and the facility's action to implement any previous plans of correction.It is noted on the monitoring report that failure to correct the non-compliance may result in, denial of application, revocation of license, filing an injunction, or issuance of an Emergency Order, as applicable.

(2) The licensing Licensing staff conducts monitoring visits at least monthly to monitor compliance and the plan(s) of correction.The same witness accompanies the licensing staff on monitoring visits whenever possible.

78.Notification is documented by the licensing staff when the provider voluntarily ceases to operate until the investigation is completed or voluntarily closes the facility, or the district attorney issues an injunction.

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