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Compliance Inspector Jessica Graham investigated the allegation that on 9/13/23 at approximately 9:30 am, Dr. Ben Johnson, facility designee, was as the facility to look at some work needing to be done on the playground. When he walked onto the playground to do some measuring, he noticed Child A (3 years old) sitting in a cozy coupe car. He walked over to the child and asked what she was doing outside, but the child didn't answer so he told her he was going to push her in the car up to the building. At about the time he got up to the building, staff walked out the door looking for Child A. She was outside, alone, for about 3 minutes according to the video footage. This allegation is substantiated based on the following rule violation.
5 CSR 25-500.182(1)(A)3., which states: "Caregivers shall provide frequent, direct contact so children are not left unobserved on the premises. "
AND
5 CSR 25-500.182(1)(A)1., which states: "Caregivers shall not leave any child without competent adult supervision."
On September 13, 2023, Dr. Ben Johnson, director of children's services, was at the facility measuring some things on the playground and noticed that Child A, age 3-years-old, was in a riding car by herself. Dr. Johnson asked Child A what she was doing but she did not respond. He was going to take Child A inside the building and that is when Holly Wilson, family advocate, came outside.
On September 14, 2023, Judy Miller, caregiver, said that she was in the classroom with Holly Wilson, family advocate. She thought there was a total of eight children in the room. Judy and Holly were documenting the children's activities on tablets. She remembers Child A sitting at a table in the room. Holly needed to leave the classroom to go get diapers down the hall so she called Hillary, program assistant, to come in for her. When Hillary came in the room they started lining the kids up to go outside. Judy counted the children and noticed that there were not eight children. She knew something was wrong, but also knew that a child was with a therapist. They left the classroom with six children, not double checking numbers. When getting to the playground door in the hallway, Hillary asked where Child A was and that is when they realized that Child A was missing.
Holly told Hillary that Child A was in the room. Her and Hillary went back to the classroom to look for Child A. Holly looked out the classroom door on the playground and saw that Child A was outside with Dr. Ben Johnson.
Room H camera
9/13/2023
8:19:59am
Video is 20 minutes long
Caregivers in the room are Judy Miller, caregiver; Holly Wilson, family advocate; First Steps therapist
There are eight children present in the room, including Child A
Child A is wearing a white t-shirt, jeans and has braids in her hair
All caregivers are interacting with children in the room
Child A is sitting at the table by herself
08:23:16 Child A gets up from the table and runs to the playground door
Holly is the only one that is facing Child A but has children around her
08:23:22am Child A pushes on the glass of the door (not using the push bar) and goes outside to the fenced in playground
There are no alarms on the doors leading to the playground
None of the caregivers in the room see Child A leave the room
08:23:29 Child A is seen by the window of the door
08:23:31 Holly walks towards the back of the room towards the door but does not notice Child A; Child A has ran out of the window area
08:23:32 All caregivers are involved with the children in the classroom; not noticing that Child A is missing
08:27:24 The therapist removes one child from the classroom, leaving six children in the room
08:27:45 Hillary Williams, program assistant, enters the classroom
08:28:00 Holly leaves the classroom leaving Hillary and Judy with six children
08:29:21 Dr. Ben Johnson is seen outside the classroom playground door; Child A is not visible
Child A was outside from 08:23:22 until 08:29:21 without adult supervision
08:29:23 Dr. Johnson walks away from the playground door window
08:29:27 Dr. Johnson is seen by the playground door window; Child A is not visible
08:29:30 Dr. Johnson walks away from the door
08:29:43 Hillary is lining up the children at the classroom door; six children are visible in the room
08:31:05 Hillary lines the children up using the walking rope
08:31:41 Judy counts the children and hesitates at the number of children she has counted
08:31:53 Judy motions Hillary to wait and walks to the counter and grabs her clipboard
08:32:02 Judy and Hillary leave the room with six children
08:33:12 Hillary walks into the classroom and goes to the bathroom
08:33:16 Holly enters the classroom and goes to the playground door
08:33:23 Holly opens the playground door and Dr. Johnson is seen standing outside
08:33:48 Hillary leaves the classroom while Holly and Dr. Johnson are talking at the playground door
08:37:37 Holly steps outside with Dr. Johnson onto the playground
08:38:24 Holly is seen outside the playground door window with Child A in a toy car
Playground camera
9-13-2023
08:29:26am
Child A is sitting in a Cozy Coupe car against the shed in the fenced in playground
08:29:28 Dr. Ben Johnson walks out of one of classroom playground doors to the playground
From viewing the video footage, it was estimated that Child A was outside for approximately eight minutes and was unsupervised for three to four minutes of that time.
5 CSR 25-500.192(5)(A) which states: "In case of accident or injury to a child, the provider shall notify the parent(s) immediately. If the child requires emergency medical care, the provider shall follow the parent's(s') written instructions."
Melissa Maness, director, contacted Child A's parent after the incident occurred. She had instructed Judy, caregiver, to call Parent A but after finding out that Judy did not contact her, she did so herself. The incident occurred around 8:20am and Parent A was not contacted until around 1:00pm.
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