3 Sisters Academy

Health Services - Parental Notification

Rule 1915.B.&C.

Tornado Drills

“1921.E. Based on record review at 12:00 p.m., S1 failed to have documentation of tornado drills that were conducted at least once per month during the months of March 2024, April 2024, and June 2024.”

Rule 1921.E.

CPR and First Aid Certifications

“1723.A.B. Based on record review at 11:20 a.m., S1 failed to have documentation that 3 of 8 staff on the premises and accessible to children have current certification in infant, child, and adult CPR through training approved by the Department. S2(DOH 2/23/23), S3(DOH 3/21/18), and S4(DOH 11/22/20) failed to have the current certification.”

Rule 1723.A.&B.

Pediatric First Aid

“1723.C. Based on record review at 11:20 a.m., S1 failed to have documentation that 3 of 8 staff on the premises and accessible to children have current certification in Pediatric First Aid through training approved by the Department. S2(DOH 2/23/23), S3(DOH 3/21/18), and S4(DOH 11/22/20) failed to have the current certification.”

Rule 1723.C.

Critical Incidents and Required Notifications

“1103.C. Based on record review at 12:00 p.m., S11 failed to notify the Department within 24 hours of notification of the following critical incident: On 3/11/2024 at 3:50 p.m., a parent notified S2 of an allegation of child abuse. S2 stated he submitted the critical incident form online, however the document was not received.”

Rule 1103.A.-C.

Daily Attendance Records - Independent Contractors

“1507.C. Based on record review at 12:31 p.m., S11 failed to have documentation of an independent contractors’ daily attendance records from 1/2/2024- 3/13/2024. S2 stated S5 misplaced the documents. There is no documentation of O2’s arrival and departure times on 2/21/2024 and 2/8/2024.”

Rule 1507.C.

Behavior Management Policy

“1509.A.8.a.b.: Based on record review/interviews at 12:30 p.m., though the center has a behavior management policy, S8 failed to follow it as S8 used a prohibited method of discipline as C1 (a two-year-old) was subject to physical punishment, corporal punishment on 3/1/2024 (time unknown). S8 was terminated on 3/13/2024 for failing to follow the center’s behavior management policy.”

Rule 1509.A.8.a.&b.

Required Staffing - Director/ Director Designee

“1707.A.1.2.: Based on record review/interviews at 12:07 p.m., S11 failed to have a qualified Director who is an on-site full time staff person at the center during the day time hours of operation (prior to 9:00 p.m.) and responsible for planning, managing, and controlling the center’s daily activities, as well as responding to parental concerns and ensuring that minimum licensing requirements are met. S2 stated he’s been working at least 32 hours every week at the center, because he thought S11 requested for him to be the director.”

Rule 1707.A.1.&2.

Independent Contractors Records

Rule 1717.A.

CCCBC-Based Determinations of Eligibility for Visitors and Contractors

“1807.C. Based on record review at 2:28 p.m., S11 failed to have documentation of a CCCBC-based determination of eligibility for child care purposes from the department was not obtained for O2, independent contractor, prior to the person being present at the center or performing services. O2 was present on 2/21/2024 and 2/28/2024, however, there is no documentation that O2’s CCCBC eligibility was verified, or have documentation of the paid, adult staff member not otherwise counted in child to staff ratios who accompanied O2 on those dates.”

Rule 1807.C.

Health Services - Parental Notification

“1915.C. Based on interviews at 3:35 p.m., S11 failed to have documentation of immediate notification to the parent when the following occurred to a child: On 12/7/2023 (time unknown), C1 had a head injury, and there is no documentation of the incident report, and parental notification.”

Rule 1915.B.&C.

Required Staffing - Director/ Director Designee

“1707.A.1.2. Based on record review, S2 failed to have a qualified Director who is an on-site full time staff person at the center during the day time hours of operation (prior to 9:00 p.m.) and responsible for planning, managing, and controlling the center’s daily activities, as well as responding to parental concerns and ensuring that minimum licensing requirements are met. S2 stated documentation was submitted to S4 as the new director.”

Rule 1707.A.1.&2.

Requests for CCCBC-Based Determinations of Eligibility

“1811.A.1. Based on record review at 11:54 a.m., S2 failed to have documentation of a CCCBC-based determination of eligibility (CCCBC) for S12 (DOH 11/27/17), prior to the individual(s) being present in the childcare facility. S12’s CCCBC expired on 11/8/23, and S12 was present at the center on the following dates: 11/8/23 - 11/10/23, 11/13/23 - 11/17/23, 11/20/23 - 11/22/23, and 11/27/23 - 11/28/23. S12 obtained an eligible CCCBC on 11/29/23.”

Rule 1811.A.&B.

Health Services - Observation

“1915.A. Based on record review at 10:07 a.m., S2 failed to have documentation of an explanation from the parent or child, when something is observed upon a child’s arrival, for the following: On 2/1/24, a child had a scratch on the cheek and in ear; On 1/3/24, a child had a scratch on forehead and bumps on left cheek; 2/5/24, a child had a scratch on cheeks, and a child had a bump on forehead.”

Rule 1915.A.