Library: Policy

340:110-1-9. Case management

Revised 12-17-18

(a) Periodic monitoring visits. Licensing staff conducts a minimum of three, unannounced monitoring visits to programs operating a full-year, and two, unannounced monitoring visits annually to programs operating less than a full-year. • 1 Licensing staff varies the monitoring visit times, including a lunch observation and an evening visit to child care centers with extended hours. • 2

(b) Ongoing monitoring. During monitoring visits, Licensing staff observes the entire facility, including the outdoor play space and transportation vehicles, when available. • 3 through 5 At, or subsequent to each monitoring visit, Licensing staff verifies:

(1) compliance with Licensing requirements;

(2) compliance with stars criteria, per Oklahoma Administrative Code (OAC) 340:110-1-8.3;

(3) new personnel records including personnel sheets and compliance with background investigations, per OAC 340:110-1-8.1; • 6 & 7

(4) personnel professional development records; • 8

(5) the Oklahoma Department of Human Services (DHS) database on applicable individuals, per OAC 340:110-1-8.1;

(6) fire and health inspections within the last 24 months, when applicable; • 9

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

(8) other documentation requiring renewal.

(1) technical assistance to licensees assisting 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. DHS may enter into a cooperative licensing agreement with a tribal licensing program or other monitoring agency. • 10

(e) Equipment inventory. Licensing staff completes Form 07LC006E, Equipment Inventory for Child Care Programs, prior to license issuance. Licensing staff or the program may complete the appropriate equipment inventory prior to a change in class and prior to a capacity increase in a child care center, day camp, drop-in, out-of-school time, part-day program, or program for sick children. Inventories document the available equipment and the items needed to comply with the equipment requirements. Licensing staff may conduct a complete inventory when concern exists about the availability of required equipment. • 11

(f) Address change.

(1) When a program moves to a new address, Licensing staff: • 12

(A) obtains an updated Form 07LC004E, Request for License Child Care Program;

(B) conducts a monitoring visit verifying that the new location meets Licensing requirements;

(C) obtains new fire and health inspections for a child care center, day camp, drop-in, out-of-school time, part-day program, or program for sick children, when applicable;

(D) obtains Oklahoma Department of Environmental Quality approval, when applicable;

(E) completes Form 07LC057E, Physical Plant, with required calculations; and

(F) requests a permit or license issuance reflecting the address change.

(2) When an address change involves care provided in a location other than the primary caregiver's residence, refer to OAC 340:110-1-6(a)(3).

(g) Program name change. When there is a program name change, Licensing staff verifies there is no ownership change, and documents the name change in the case file and database. A new Form 07LC004E, Request for License Child Care Program, reflecting the program name change is completed. Licensing staff requests a permit or license issuance reflecting the new program name. • 13

(h) Director change. When there is a director change, Licensing staff:

(1) verifies the new director meets qualifications;

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

(3) obtains references;

(4) obtains an appropriate, completed Form 07LC117E, Compliance Review for Child Care Programs, from the director, when the director has no previous director experience;

(5) notifies the new director of current personnel, who are granted waivers; and • 14

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

(i) Master teacher change. When an individual replaces a master teacher:

(1) Form 07LC031E, Probationary Master Teacher Agreement, is completed;

(2) the probationary master teacher is granted a one-year probationary period to fulfill the master teacher educational qualifications per applicable Licensing requirements and Quality Rating and Improvement System (QRIS) criteria, when applicable; and

(3) Licensing may extend the probationary period for a second year, providing the probationary master teacher is actively pursuing educational qualifications as identified on Form 07LC031E. • 15

(j) Primary caregiver change. When there is a primary caregiver change, Licensing staff:

(1) verifies the primary caregiver meets qualifications;

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

(3) obtains references;

(4) notifies the new primary caregiver of current personnel, who are granted waivers; and

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

(k) Facility household change. Facility household changes are documented on the monitoring summary. Form 07LC096E, Criminal History Review Request for Programs, must be submitted prior to a new adult residing in the facility. When there is a new adult residing in a facility, the required documentation includes:

(1) the applicable page of Form 07LC004E, Request for License Child Care Program, completed by the new adult;

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

(3) a DHS database search.

(l) Change in ownership. When there is a change in ownership or a change in the form of business organization of a child care program, the case is closed and a new Form 07LC004E, Request for License Child Care Program, is obtained. Prior to permit or license issuance, the program must be in compliance with background investigations, per OAC 340:110-1-8.1. A permit may be issued when a monitoring visit without numerous, repeated, or serious non-compliances was conducted within the past 60-calendar days. A full-monitoring visit is conducted within 14-calendar days of change of ownership verifying the new owner meets minimum Licensing requirements. • 16

(m) Transitional change of ownership. When a program requests a transitional change of ownership (1) through (6) of this subsection are followed.

(1) Licensing staff conducts a monitoring visit within five DHS-business days, verifying compliance with Licensing requirements and, obtains: • 17

(A) Form 07LC015E, Transitional Change of Ownership, completed by the current and prospective owners;

(B) Form 07LC004E, Request for License Child Care Program, completed by the prospective owner; and

(C) updated program personnel information on Form 07LC002E, Personnel Summary, verifying that the prospective owner employs the same personnel as the current owner, at the time of transitional change of ownership.

(2) Transitional change of ownership procedures for star certification are met, per OAC 340:110-1-8.3; when applicable.

(3) Periodic and ongoing monitoring is maintained, per (a) and (b) of this Section.

(4) All Licensing monitoring and correspondence are provided to both the current and prospective owners.

(5) Change of ownership procedures are followed, per (l) of this Section by the end of 90-calendar days, when applicable.

(6) When programs notify Licensing that transitional change of ownership is no longer proceeding, Licensing staff verifies program operation status and consults with the supervisor for appropriate action.

(n) Change in class. When a program requests a change in class, procedures in (1) through (2) of this subsection are followed.

(1) The case is closed and a new Form 07LC004E, Request for License Child Care Program, is required, when a:

(A) family child care home converts to a child care center, day camp, drop-in, out-of-school time, part-day program, or program for sick children; or

(B) child care center, day camp, drop-in, out-of-school time, part-day program, or program for sick children converts to a family child care home.

(2) Other requests for change in class do not require case closure and, documentation includes: • 18

(A) a request in writing from the owner;

(B) a new Form 07LC004E, Request for License Child Care Program, with updated information;

(D) the appropriate equipment inventory, when applicable;

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

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

(G) appropriate class and monitoring frequency plan database updates. • 1

(o) Capacity increase or decrease. When a program requests a capacity increase or decrease, it is documented on Form 07LC080E, Licensing Services Supplemental Information, and must be approved by the supervisor. The program must not have a history of numerous, repeated, or serious non-compliance, and provide: • 19

(1) the reason for the increase;

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

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

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

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

(6) verification of the required number of master teachers. • 20

(p) Inactive programs. A program is in inactive status when care was not provided for more than 90-calendar days. • 21

(1) A program remaining open after 90-calendar days submits a request in writing, including a statement that the owner will notify Licensing prior to resuming care. Licensing staff verifies compliance with requirements prior to resuming care.

(2) The program is contacted by Licensing staff, a minimum of every four months by phone, letter, or email to update program status including new household members or other program changes, per (k) of this Section.

(3) Voluntary closure is discussed with the owner and an agreement to close is reached, when possible.

(4) Licensing staff visits the inactive program, at least once during the 12-month timeframe verifying compliance with Licensing requirements until closure is final or the program resumes care.

(5) When an address change occurs when a program is in inactive status, a monitoring visit is required and address change procedures are followed per (f) of this Section.

(q) Inactive program closure. Procedures (1) - (4) of this subsection are followed when closing an inactive program.

(1) To verify program status, Licensing staff contacts the owner during the 12th month of inactive status.

(2) Licensing documents program status on Form 07LC080E, Licensing Services Supplemental Information, and notifies the owner the case will be closed when care does not resume, prior to the end of the 12th month.

(3) When care was not provided for 12-consecutive months or more, Licensing staff provides a letter notifying the owner of case closure within 10-calendar days of letter receipt, unless Licensing is notified care resumed.

(4) The case is closed and the owner must reapply and be approved for a new license prior to resuming care, per OAC 340:110-1-6.

(r) Response to a child death. When notified of a child death while in child care, Licensing staff:

(1) completes Form 07LC079E, Child Death Report, and forwards it to the statewide licensing coordinator or designee: andz

(2) visits the program as soon as possible, unless advised otherwise by law enforcement officials. • 22

(s) Serious incident reports. The supervisor submits serious incident reports to the regional programs manager, county director, and statewide licensing coordinator. • 23

(t) Self-reported incidents. When a provider self-reports a non-compliance incident, Form 07LC080E, Licensing Services Supplemental Information, is completed and the Licensing database is updated. • 24

INSTRUCTIONS TO STAFF

Revised 6-1-22

1. Monitoring visits.

(1) Staff safety. Supervisors are consulted for appropriate action regarding program monitoring safety concerns. Appropriate action may include the utilization of a witness or coordination with law enforcement officials.

(2) Requirements. After each monitoring visit, Licensing staff enters the monitoring frequency plan reflecting the required number of annual monitoring visits on the Licensing database. Monitoring frequency plan changes are reviewed with the supervisor. Examples of the required number of monitoring visits annually, include:

(A) one for inactive child care centers, day camp, drop-in, out-of-school time, part-day program, programs for sick children, or family child care home;

(B) two for part-year programs;

(C) three for programs with a history of compliance;

(D) six for request for licenses, six-month permits, and changes in class, except for large family child care homes changing to family child care homes; and

(E) 12 for programs with a pattern of numerous, repeated, or serious non-compliances.

(3) Frequency of monitoring visits.

(A) Programs operating part-year require only two visits annually.

(B) Programs operating a full-year program, including those offering only part-time care during the week, require three visits annually.

(C) When Licensing staff visits a program between monitoring visits for purposes, such as picking up paperwork, consultation on a specific issue, verifying repairs were made, or needed items were purchased, a full-monitoring visit is not required.

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

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

(iii) A full-monitoring visit is conducted when numerous, repeated, or serious non-compliance is observed during this visit.

(D) Partial-monitoring visits also include, documentation regarding:

(i) completion of the first page, including staff-child ratios;

(ii) weapons;

(iii) Child Welfare Services (CWS) involvement, criminal history, and new household members;

(iv) involvement with tribal agencies; and

(v) special needs certifications.

(E) Scheduled annual star criteria reviews are not counted towards the required number of monitoring visits.

(4) Reduced monitoring visits. When caseloads prevent Licensing staff from conducting the required number of monitoring visits, the supervisor consults with Licensing staff on case management and the number of required visits may be reduced, when approved by the regional programs manager (RPM). This adjustment is approved by the supervisor and documented in the case record.

(5) Verifying staff-child ratio. When the only purpose of a monitoring visit is providing or receiving materials, staff-child ratios may not need verification. Staff-child ratios are verified during partial- and full-monitoring, and other visits involving follow-up, complaint investigations, equipment inventories, or stars monitoring.

(6) Documentation of requirements not reviewed during monitoring visits. Licensing staff indicates on the monitoring checklist areas of requirements not reviewed during partial- or full-monitoring visits.

(7) Case records. Case record information is accurately maintained within the Licensing database. Confidential information, such as identifying child information, including initials, is documented on Form 07LC080E, Licensing Services Supplemental Information, and maintained in the case record's confidential section.

2. Monitoring visits to:

(1) a center with extended hours, are conducted between 8 p.m. and 10 p.m. unless extenuating circumstances exist, such as a complaint regarding a different time period or an unsafe neighborhood. Overnight child care is care provided between midnight and 6 a.m.;

(2) programs for lunch observation, typically occur between 11 a.m. and 1 p.m.; however, lunch may be observed outside of these timeframes; and

(3) programs with limited hours of operation, such as weekends or evenings, are made only during program hours of operation, unless complaint allegations require other observation times, or concerns exist. Varying times of visits is not required. Specific hours of operation are documented on the monitoring checklist.

3. When monitoring all licensed programs, Licensing staff:

(1) documents observations and discussions on the appropriate monitoring checklists, enters the information from the monitoring checklists in the Licensing database, and provides monitoring summary copies to the program's owner/operator;

(2) may receive documents from programs, other agencies and outside sources. Licensing notations are made on a copy of the received document;

(3) documents non-compliances for missing immunization records. However, for missing immunizations:

(A) non-compliance is not documented;

(B) a recommendation for programs to refer parents to the Oklahoma State Department of Health (OSDH) or to the child's licensed physician is documented in monitoring summary discussion area; and

(C) for confidentiality, documentation of children's names, when applicable is recorded on Form 07LC080E, Licensing Services Supplemental Information;

(4) monitors weapons, per (A) through (D) of this paragraph.

(A) During the initial program visit or when Licensing staff has not previously visited the program, Licensing observes weapon and ammunition storage, per Licensing requirements.

(B) During subsequent visits, Licensing staff ask about weapons and verify storage is locked.

(C) Weapons and ammunition are not removed from locked containers for Licensing observation.

(D) Storage locations are not viewed in children's presence and for confidentiality are documented on Form 07LC080E, Licensing Services Supplemental Information;

(5) follow photographing procedures in (A) through (C) of this paragraph.

(A) When photographs are needed for non-compliance determination:

(i) Licensing documents discussion of the photographs with the operator; and

(ii) photographs are:

(I) not enhanced or altered; and

(II) scanned, and placed in the case record, along with Form 07LC080E, Licensing Services Supplemental Information, documenting discussion with supervisor.

(B) Photographs are deleted from cell phone devices.

(C) When the operator is uncooperative, do not proceed with taking photographs, discuss the alternatives, and consult with supervisor for appropriate action;

(6) follow (A) through (D) of this paragraph when observation of an Electronic Benefits Transfer (EBT) card occurs. Licensing staff:

(A) documents the observation on Form 07LC080E, Licensing Services Supplemental Information;

(B) photographs the front and back of the EBT card;

(C) refers information to the Office of Inspector General (OIG), including Adult and Family Services (AFS) Child Care Subsidy at childcarecontracts@okdhs.org, with the EBT card photograph attachment; and

(D) deletes photographs from the cell phone device; and

(7) consults with the supervisor and RPM when required documentation includes names of all children present, such as, programs with a pattern of over-capacity, numerous complaints and non-compliances, or are considered for negative sanction. For confidentiality, children's names are documented on Form 07LC080E, Licensing Services Supplemental Information.

4. In addition to Instruction # 3 of this Section, when monitoring a family child care home, Licensing staff:

(1) is cognizant of the home environment and demonstrates respect for the family's privacy;

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

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

(4) monitors immunizations for children present, regardless of age:

(5) monitors vehicles and refrigerator temperature, annually and, when concerns exist;

(6) documents the full names of all adults present during the monitoring visit in the monitoring summary discussion area; and

(7) monitors visiting children other than children in care, per (A) through (C) of this paragraph.

(A) A caregiver's child's visiting friend, 5 years of age and older and able to go home is not counted toward licensed capacity.

(B) Children under 5 years of age with no parent present are counted toward licensed capacity.

(C) Licensing staff discuss with the caregiver how he or she will meet the children's needs and provide proper supervision. The discussion is documented on the monitoring summary.

5. In addition to Instruction # 3 of this Section, when monitoring a child care center, day camp, drop-in, out-of-school time, part-day program, or program for sick children, Licensing staff monitors immunizations by:

(A) reviewing a sample of immunizations for children birth through 2 years of age, unless (B)(ii) of this Instruction applies; or

(B) not reviewing immunization records:

(i) for children attending school; or

(ii) when an OSDH representative responsible for immunization monitoring reviewed the records within the last six months. Licensing documents an OSDH review on the monitoring summary.

6. Licensing maintains program personnel sheets in the case record for 12 months after employment ends. Personnel sheets must be purged prior to public viewing.

7. Licensing staff documents personnel's Social Security name changes on Form 07LC080E, Licensing Services Supplemental Information, and notifies the Office of Background Investigations (OBI) to update the database. A new personnel information sheet is not required. When the director's name changes, due to director credential implications, Licensing notifies the Center for Early Childhood Professional Development.

8. Licensing staff reviews the one-time and annual professional development requirements when concerns exist and at the annual professional development review. Professional development is verified for program personnel and home providers, per specific Licensing requirements.

9. Procedures for monitoring fire and health inspections in (1) through (3) of this Instruction are followed.

(1) Licensing reviews on-going fire and health inspections and copies are not required for the case record.

(2) When the inspection indicates Licensing violations, it is documented as non-compliance and a copy is maintained in the case record. However, when health inspections are not conducted timely, Licensing staff notify an appropriate Child Care Services (CCS) designee and it is not documented as a non-compliance.

(3) Licensing staff consults with the supervisor and RPM when OSDH representatives report immunization record concerns or the program is not cooperating with immunization reviews.

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

(1) After each monitoring visit, Licensing staff provides a completed monitoring checklist and summary copy to the assigned tribal licensing staff or other monitoring program representatives.

(2) Monitoring visit reports conducted by the tribal licensing staff or other monitoring program representatives are provided to Licensing staff who enters the visit in the Licensing database identifying it as a visit conducted by the tribe or other monitoring program representatives. The monitoring visits count toward the required number of program visits.

(A) All tribal monitoring visits are considered case history. A minimum of two visits annually must be conducted by CCS staff.

(B) Case action approvals are based only on CCS Licensing monitoring information.

(3) All case record information including confidential information, except for CWS reports, is available to tribal licensing staff or other monitoring program representatives on request.

(4) Licensing staff coordinates, when appropriate, with the tribal licensing staff or other monitoring program representatives to conduct complaint investigations, complaint follow-up, non-compliance follow-up, and office conferences.

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

11. Equipment inventory. The inventory date and needed equipment is documented on the monitoring checklist. Only the initial inventory of a new program and a subsequent inventory increasing capacity are maintained in the case record.

12. Address change.

(1) When the new address is outside of Licensing staff's area, the case is transferred to appropriate Licensing staff, conducting the monitoring visit.

(2) When Licensing staff is notified of the address change, Licensing staff advises the owner to also report the address change to AFS Child Care Subsidy at childcarecontracts@okdhs.org.

(3) The new Form 07LC004E, Request for License Child Care Program, is for information purposes only. The case is not closed and reopened and the license number remains the same.

(4) New address information is submitted to the Licensing staff's supervisor, the supervisor of the receiving Licensing staff, and AFS Child Care Subsidy, at childcarecontracts@okdhs.org. The receiving Licensing staff enters the new address, Licensing staff, and supervisor information on the Licensing database. Critical information on non-compliant cases is shared with the receiving Licensing staff and supervisor.

(5) Licensing staff notifies the statewide licensing coordinator of the address change. The statewide licensing coordinator or designee issues a new program license reflecting initial license date and a copy is provided to Licensing staff.

(6) When a child care center, day camp, drop-in, out-of-school time, part-day program, program for sick children, or family child care home reports an address change, current program personnel do not acquire new employment dates or require a new background checks.

13. Licensing staff notifies the statewide licensing coordinator of the name change. The statewide licensing coordinator or designee issues a new license reflecting initial license date to the program and a copy is provided to Licensing staff.

14. When requested, directors are provided a waiver notice copy and it is maintained in the program's compliance file.

15. Licensing staff reviews the identified educational goals on Form 07LC031E, Probationary Master Teacher Agreement.

(1) When the first year probationary educational goals identified are:

(A) not met, Licensing staff may consult with supervisor regarding:

(i) second probationary year approval; and

(ii) master teacher non-compliance documentation and appropriate action; or

(B) met, Licensing staff extends the probationary period for a second year.

(2) When the second probationary year educational goals identified on Form 07LC031E are not met, Licensing staff consults with supervisor and program operator for acceptable plans of correction and extension of time to comply, when applicable, per star level participation.

16. (a) The RPM is consulted for appropriate action regarding ownership changes.

(b) Licensing staff advises the owner Form 08CC001E, Child Care Provider Contract, is canceled when the program's case is closed. The owner is referred to AFS Child Care Subsidy, at childcarecontracts@okdhs.org to request a new contract so child care is not disrupted for families receiving subsidized child care benefits.

(c) When a family child care home changes business entity, Licensing staff consults with a supervisor to determine when a six-month permit is required.

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

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

(f) New facility construction, additional square footage not previously included in licensed capacity, and kitchen alterations affecting food service, require new fire and health inspections.

(g) Previous inspections copies in (d) and (e) of this Instruction are maintained in the new case record.

17. Transitional change of ownership.

(1) Monitoring visits are conducted under the current owner's program and copies are maintained in the prospective owner's case record.

(2) All Licensing correspondence copies are maintained in both the current and prospective owners' case records.

(3) All of the current owner's Licensing history is available to the prospective owner on request, including revocation or denial of license information.

(4) Licensing staff follows-up with program when the 90-calendar day timeframe is approaching verifying program operation status in efforts to avoid disruption of care.

18. Change in class.

(1) Change in class includes a family child care home becoming a large child care home or a child care center, day camp, drop-in, out-of-school time, part-day, or program for sick children becoming a different program type.

(2) When a family child care home 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.

19. Capacity change. The procedure for a capacity increase or decrease is outlined in (1) through (4) of this Instruction.

(1) Increase. Programs must provide a written request for capacity increase. Licensing staff:

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

(B) ensures the director completes and submits Form 07LC006E, Equipment Inventory for Child Care Programs, reflecting adequate equipment for the increase; and

(C) does not recommend to increase capacity when the program has numerous, repeated, or serious non-compliance with requirements. The RPM is consulted regarding requests for increase when the only serious non-compliance was the facility exceeded capacity.

(2) Decrease. When decreasing capacity, Licensing staff updates the floor plan on Form 07LC057E, Physical Plant, indicating rooms available for children's use.

(3) Capacity increase or decrease recommendations. Capacity increase or decrease recommendations are documented on Form 07LC080E, Licensing Services Supplemental Information, and submitted to the supervisor.

(4) Approval. When capacity change is approved, the statewide licensing coordinator or designee issues the program a license reflecting the new capacity and initial license issuance date. A license copy is provided to Licensing staff.

20. Programs need the required number of qualified master teachers for capacity increase and applicable star level certification. All required master teachers must meet educational criteria and are not eligible for probationary periods.

21. Inactive programs.

(1) Licensing staff emails:

(A) the appropriate stars outreach specialist; and

(B) AFS Child Care Subsidy at childcarecontracts@okdhs.org, regarding the status of inactive care. The email includes:

(i) the reason for inactive status;

(ii) the inactive status effective date;

(iii) the length of time the program anticipates being inactive; and

(iv) a request for AFS Child Care Subsidy to notify CCS of contract cancellation or point of service machine deactivation; and

(C) AFS Child Care Subsidy regarding the date care resumed.

(2) A full-monitoring visit is conducted 12 months from the last full visit, not from the time the program was considered inactive. This monitoring visit may be announced to ensure someone is present.

(3) When a family child care home primary caregiver is employed outside of the home during inactive status, the case remains open. Licensing staff documents on Form 07LC080E, Licensing Services Supplemental Information, the provider's understanding when care resumes, employment outside the home, during the hours of care is prohibited.

(4) When programs are certified at a two-star level or higher, procedures, per Oklahoma Administrative Code (OAC) 340:110-1-8.3, are also followed.

22. Child death. When notified of a child's death occurring in child care, Licensing staff:

(1) determines and documents what occurred. Documentation includes:

(A) the child(ren)'s names, ages, and number of children and personnel present at time of incident;

(B) what supervision was provided during this time;

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

(D) personnel's response upon finding the child; and

(E) names of personnel involved, when possible; and

(2) obtains pertinent program records, including attendance records for children and personnel present at time of incident;

(3) notifies the supervisor, county director, RPM, statewide licensing coordinator, and CCS director; and

(4) considers whether the death is possibly related to Sudden Infant Death Syndrome (SIDS) or other sleep related causes and, when related to an infant death:

(A) documents:

(i) how the child was dressed at the time of the incident;

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

(iii) rest equipment's condition;

(iv) observations regarding the bedding and other items in the sleeping area; and

(v) caregiver or personnel training, such as safe sleep, cardiopulmonary resuscitation (CPR), and first aid certification;

(B) notifies the supervisor, county director, RPM, statewide licensing coordinator, and CCS director;

(C) notifies OSDH Maternal and Child Health Safe Sleep/SIDS coordinator; and

(D) obtains verbal or written verification confirming the cause of death from the appropriate authority.

23. Serious incident.

(1) Serious incidents include at least, incidents:

(A) resulting in a child's serious injury or death, such as a shaken baby, a drowning or near drowning, or a traffic accident resulting in serious injury;

(B) placing a child at a high risk for death or injury, such as a child leaving a program without personnel's knowledge, a child left at a location away from the program, a child left unattended in a vehicle, or a child left alone in a program; and

(C) such as fire, flood, or tornado resulting in significant facility damage.

(2) In addition to Instructions to Staff # 22 (1)(A) and (2) of this Section, a serious incident report also includes:

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

(B) the incident date and time;

(C) a description of child(ren)'s injuries or facility damage;

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

(E) a summary of other contacts involved in the investigation, such as other OKDHS divisions or law enforcement officials;

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

(G) names of involved personnel.

24. Only owners, directors, personnel acting in the role of director, or primary caregivers can self-report. When other program personnel self-report non-compliances, the self-reports are considered complaints.

(1) When discussions with the program operator determine a non-compliance did not occur, Licensing staff:

(A) documents the discussion on Form 07LC080E, Licensing Services Supplemental Information; and

(B) provides a letter to the program, including a copy of Form 07LC080E, Licensing Services Supplemental Information.

(2) Licensing staff's response to a self-reported non-compliance, per OAC 340:110-1-9.3, is based on:

(A) the degree of risk to children;

(B) whether the provider could have prevented the non-compliance;

(C) the provider's timeliness and effectiveness of the response; and

(D) supervisory consultation when self-reporting involves serious non-compliances.

(3) When Licensing determines non-compliance occurred and the program operator took appropriate action, a monitoring visit is not required. Licensing staff:

(A) documents the discussion on Form 07LC080E, Licensing Services Supplemental Information;

(B) provides a letter to the program including a copy of Form 07LC080E, Licensing Services Supplemental Information, including the:

(i) self-reporting date;

(ii) non-compliance description;

(iii) action taken by the program;

(iv) program's plan of correction;

(v) request for completion of Form 07LC037E, Notice to Comply, when applicable, per OAC 340:110-1-9.3(d)(7); and

(vi) statement "a self-reported serious non-compliance may be considered when reviewing the case for an Emergency Order, denial of request for license, license revocation, or a stars reduction";

(C) documents the phone call in the database as "other contacts" and the self-reported incident does not appear on the child care locator.

(4) When Licensing determines non-compliance occurred and the program operator did not take appropriate action, a monitoring visit is required. All necessary documentation is entered on the monitoring checklist and summary. Additional follow-up, including a letter, is based on the seriousness of the non-compliance. The visits are entered as monitoring visits in the database.

(5) When a self-reported incident requires an abuse or neglect referral to CWS, per OAC 340:110-1-9.2(i), and CWS accepts the referral for investigation, Licensing considers the self-reported incident a complaint.