Library: Policy
340:110-1-9.2. Complaint investigations
Revised 6-1-22
(a) Legal basis. The Oklahoma Child Care Facilities Licensing Act (Act), Section 406 of Title 10 of the Oklahoma Statutes (10 O.S. § 406), mandates that Oklahoma Human Services (OKDHS) conduct a full complaint investigation alleging violation against the Act or Licensing requirements.
(b) Complaint receipt. Complaints may be made to Licensing in writing, in person, by phone, or electronically. • 1
(c) Complaint information. Licensing staff obtains as much relevant information as possible from the complainant. • 2
(d) Screening complaints. Licensing staff accepts a complaint for investigation when alleging: • 3
(1) non-compliance with Licensing requirements;
(2) violation of the Act;
(3) unlicensed facility operation; or
(4) abuse or neglect of a child in care.
(e) Complaint risk levels. Licensing staff determine risk levels based on the degree of harm or danger to children in care. Risk levels are used to ensure investigations occur in a timely manner. • 4
(1) Risk level I complaints. Risk level I complaints indicate a child is in imminent risk of serious physical harm. The risk level is not influenced by the removal of a child from the facility when other children remain in care. Investigations are initiated immediately or no later than 24 hours after receipt by Licensing unless awaiting a Child Welfare Services (CWS) or local law enforcement investigation; excluding weekends and holidays when the facility is closed. Non-compliances with licensing requirements include, but are not limited to:
(A) alleged physical or sexual abuse;
(B) the presence or use of illegal drugs while children are in care;
(C) drug distribution;
(D) children left in the facility or in a vehicle without anyone present;
(E) facility temperatures;
(F) infant sleep environments and safe-sleep training;
(G) caregiver's threatening or impaired behavior;
(H) severe understaffing or severe over licensed capacity;
(I) child passenger restraints;
(J) Emergency Order violation;
(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 individuals identified as restricted or Restricted Registry 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 10-calendar days of receipt by Licensing, unless requested to delay the investigation by CWS or local law enforcement. Non-compliances with licensing requirements include, but are not limited to:
(A) leaving children with underage personnel;
(B) alleged physical abuse from personnel no longer working in the facility;
(C) inappropriate discipline, when no injury is reported;
(D) diapering or toileting;
(E) hazardous equipment;
(F) transporting without a valid driver license, liability insurance, or parent permissions;
(G) lack of supervision; or
(H) minor understaffing or minor over licensed capacity.
(3) Risk level III complaints. Risk level III complaints do not indicate imminent risk of harm and there are no injuries alleged. Serious non-compliances, per Oklahoma Administrative Code (OAC) 340:110-1-9.3 are not considered risk level III complaints. Investigations are initiated within 15-calendar days of receipt by Licensing; including when a phone investigation is appropriate, per (g) of this Section. Non-compliances with licensing requirements include, but are not limited to:
(A) inadequate meal service;
(B) lack of play equipment;
(C) quarterly vehicle maintenance;
(D) program records and documentation;
(E) inappropriate television or media use; or
(F) facility cleanliness.
(f) The investigation. Licensing staff conducts a full investigation, obtaining sufficient information to determine a finding. • 5
(g) Phone investigation. With supervisory approval, Licensing staff may investigate a complaint by phone. The investigation discussion is documented on Form 07LC080E, Licensing Services Supplemental Information, including an agreed-upon plan of correction, when necessary. A copy is provided to the operator. A complaint is investigated by phone only when:
(1) the alleged non-compliance does not place children at risk of harm, such as, 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 within the previous 12 months from complaint receipt; and
(3) a monitoring visit was conducted in the last three months with substantial compliance documented.
(h) Unlicensed facility investigations. When a complaint alleging operation of an unlicensed facility is received, the procedure, per OAC 340:110-1-13 is also followed.
(i) Child abuse and neglect complaints. On receipt of abuse or neglect allegations of a child in care, Licensing staff immediately notifies the Licensing supervisor and submits a CWS referral. When the allegation involves child abuse or neglect or a report indicating a child is in imminent risk of serious physical harm, the regional programs manager (RPM) is also notified. • 6
(j) Findings. After investigation completion, the Licensing staff, in consultation with the supervisor, as appropriate, determines the complaint finding as substantiated or unsubstantiated.
(1) Substantiated. A substantiated finding is determined when some credible evidence indicates the facility violated Licensing requirements or the Act.
(2) Unsubstantiated. An unsubstantiated finding is determined when:
(A) insufficient evidence exists to fully determine whether a violation occurred; or
(B) no violation of Licensing requirements or the Act occurred.
(k) Documentation of findings. Upon investigation completion, Licensing staff:
(1) documents the findings; • 7
(2) notifies the provider of complaint allegations and findings by providing:
(A) a complaint findings cover letter;
(B) Form 07LC081E, Licensing Complaint Report Summary; and
(C) Form 04CP004E, Child Welfare Investigative Summary Notification to Child Care Licensing Services, when applicable; and
(3) updates the Licensing database and closes the complaint. Licensing staff and a supervisor complete the complaint review checklist.
(l) Heinous and shocking abuse findings. Per 10 O.S. § 406, when Licensing receives notification from CWS of heinous and shocking abuse findings by a person responsible for the child's health, safety, or welfare as defined, per 10A O.S. §1-1-105, Licensing contacts the program by email immediately or not later than one-business day after the substantiated finding notification. • 8
(m) Notice to Comply. When a complaint allegation is substantiated, Licensing staff advises the facility to correct the violations immediately and requests the facility complete Form 07LC037E, Notice to Comply, per OAC 340:110-1-9.3(d)(7). Licensing staff updates the Licensing database with plan of correction information.
(n) Summary of facts. Licensing provides facility directors and owners or primary caregivers a summary of the facts used to evaluate and determine the complaint findings. • 9
(o) Complaint overview. Licensing staff completes an overview of completed complaint investigations on Form 07LC080E, Licensing Services Supplemental Information. This overview provides an investigation summary of how the complaint findings were determined and is maintained in the case record's confidential section. • 10
Revised 6-1-22
1. When the complaint is made in person or by phone, Licensing staff assists the complainant by:
(1) advising of allegations representing non-compliance;
(2) responding to complainant's concerns;
(3) discussing confidentiality, such as, the complainant's identity is kept confidential unless legal action or a referral to local law enforcement officials becomes necessary;
(4) eliciting appropriate information. When subjective terms, such as "drunk" or "crazy" are used, 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 Licensing staff making an unannounced visit or a referral to Child Welfare Services (CWS); and
(6) discussing the interviewing of complainant's children, when necessary and appropriate.
2. The information is documented on Form 07LC012E, Licensing Complaint, and entered in the Licensing database by using complaint key words. The information requested includes the:
(1) date and time the complaint was received;
(2) facility name, address, and phone number;
(3) complainant's name, address, phone number, and program relationship, such as employee, parent of a child in care, or neighbor;
(4) complainant's source of information, such as, personal observation or information from another individual; and
(5) specific information regarding the complaint allegations including:
(A) a description of the circumstances;
(B) the name or identity of personnel involved;
(C) the child's name and age, who was involved or affected by the alleged non-compliance;
(D) the date(s), time(s), and place(s) the alleged non-compliance(s) occurred;
(E) the names of other individuals with relevant information; and
(F) if the complaint was discussed with the director or primary caregiver.
3. Licensing staff determines one of the dispositions in this Instruction.
(1) Complaints or concerns not meeting criteria, per Oklahoma Administrative Code (OAC) 340:110-1-9.2(d) are discussed with the complainant, and when appropriate, a referral is made to another entity, such as local law enforcement officials, Adult and Family Services (AFS), or the Office for Civil Rights.
(2) A complaint alleging Licensing requirement violation or an unlicensed facility is investigated by Licensing staff. This information is recorded as a complaint regardless of the caller's purpose. Licensing staff in the area where the facility is located, is notified as soon as possible, and Form 07LC012E, Licensing Complaint, is forwarded to Licensing staff.
(3) A complaint alleging child abuse or neglect is immediately referred to CWS, with a copy of Form 07LC012E, Licensing Complaint. The referral is documented on the form. When an immediate response to the referral is not received, Licensing staff follows up the next Oklahoma Department of Human Services (DHS)-business day to obtain a response.
(A) Complaints referred to CWS include alleging harm or threatened harm to a child's safety occurring through non-accidental physical or mental injury, sexual abuse, neglect, or failure or omission to provide protection from harm or threatened harm.
(B) When Licensing staff is unsure a complaint meets CWS investigation criteria, the complaint is referred to CWS and the decision to accept the referral is made by CWS staff.
(C) Sex play between children is referred to CWS. Licensing investigates this type of allegation with regard to children's supervision.
(4) When a complaint alleging illegal activity is received, all referral information including the complainant's name, is forwarded to appropriate entities. The guidelines in (A) through (D) of this paragraph are met.
(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 filed in the case file, and the supervisor is notified. Licensing staff is responsible for follow up with local law enforcement officials to determine and document the investigation's outcome.
(B) When the complaint allegation includes illegal drug activity, Licensing staff obtains as much information as possible from the complainant, including the individual's behaviors when it is alleged he or she was under the influence of drugs. Even when the alleged drug activity occurred when children were not in care, every complaint is referred to local law enforcement officials and, when the program has a provider contract, to the Office of Inspector General (OIG). Licensing staff is responsible for follow-up with local law enforcement officials regarding their involvement prior to complaint submission to OIG. However, when a response is not received from local law enforcement officials within 48-hours from complaint receipt, Licensing staff forwards the complaint to OIG. The OIG referral is documented on Form 19MP001E, Office of Inspector General (OIG) Referral Form, and includes date, contact, including attempted contact, information regarding local law enforcement official referral, and a copy of Form 07LC012E, Licensing Complaint. On receipt of the referral, OIG contacts the local law enforcement officials to determine who conducts the investigation or if a joint investigation will be conducted. Licensing staff is responsible for follow-up with OIG to determine and document the investigation outcome.
(C) Prior to facility visits, Licensing staff informs and consults with OIG regarding the restrictions of individuals involved in the allegation.
(D) Complaints alleging the use of illegal drugs during child care hours may be addressed with the caregiver after consultation with local law enforcement officials and OIG. Complaints alleging illegal activity of a more serious nature, such as drug trafficking are not investigated by Licensing staff.
(5) A complaint alleging discrimination is discussed with the complainant. The complainant is referred to the program in efforts to resolve the issue. When the complaint remains unresolved, Licensing staff refers the complainant to the Office for Civil Rights documenting the referral on Form 07LC080E, Licensing Services Supplemental Information.
(6) Information in a complaint received from another division within DHS or an agency responsible for monitoring child care facilities, such as OIG or local health or fire departments, may be deemed valid when documented in writing by the agency representative. Licensing staff determines when observation is a non-compliance. The program is advised of the report, is requested to complete Form 07LC037E, Notice to Comply, when applicable, per OAC 340:110-1-9.3(d)(7), and is given an opportunity to respond.
(7) The supervisor is notified of complaints:
(A) when the alleged non-compliance caused or could cause serious harm to a child in care;
(B) when the program has numerous, repeated, or serious non-compliance with requirements;
(C) when the alleged non-compliance was previously addressed on Form 07LC037E, Notice to Comply;
(D) referred to CWS or local law enforcement officials; or
(E) receiving special attention, such as from the media or a legislator.
(8) When a director or owner self-reports an allegation Licensing staff informs the supervisor and consults with the regional program manager (RPM), when necessary to determine when potential harm to children warrants an investigation.
4. When necessary, Licensing staff consults with supervisor to determine the appropriate risk level, complaint initiation time frame, or follow-up based on:
(1) the program's case history;
(2) the length of time since the alleged incident occurred;
(3) the allegation's severity; including the number and ages of children involved;
(4) Licensing staff's current workload and other pending complaint investigations; and
(5) necessary coordination with CWS or other agencies.
5. The investigation generally includes:
(1) a review of the complaint allegations to ensure staff is thoroughly familiar with the details and specific information. Whenever possible, prior to making program contact, Licensing staff reviews all appropriate DHS records to obtain other preliminary information, as appropriate;
(2) an unannounced visit. The purpose of the visit and allegation descriptions using "key words" are initially discussed with the operator. Licensing documents in discussion key words were discussed with the director, owner, or both, when applicable. Prior to the complaint investigation conclusion, the full allegation is explained and discussed with the director or primary caregiver. Licensing staff does not identify the complainant;
(3) consideration of a safety plan. Based on allegation severity and/or information gathered during the complaint investigation, Licensing staff discusses with the operator and documents on Form 07LC080E, Licensing Services Supplemental Information, appropriate methods of protecting children during the investigation. With State Office approval, Licensing staff may request the owner to voluntarily cease care, or require specific restrictions of contact with children for the alleged perpetrator, pending the investigation outcome. The RPM is notified of all situations involving a request for voluntary cease care. When the owner refuses to cease care or adequately protect children and children are considered at imminent risk of harm, Licensing staff discusses and documents in discussion the possibility of an injunction or an Emergency Order;
(4) a review of available records, such as the case file, children's and personnel files and attendance records, injury logs, medical and transportation permission records, child care subsidy records, food program records, or local law enforcement reports;
(5) interviews with the complainant, witnesses, and complainant's children, when necessary and appropriate, and others having relevant information, such as program personnel or food program employees. Additional parent and child interviews are not conducted for Risk Level III complaints. When sufficient investigative information for determination of a finding is obtained through personnel interviews, observation, and/or available records and documents, additional parent and child interviews are not conducted. Interviews are no longer conducted when sufficient information is obtained to determine a finding. An interview:
(A) is conducted when it would provide more complete or accurate information than observation alone;
(B) is scheduled at a time and location as to not present an undue hardship for the interviewee;
(C) is limited to questions relating to current complaint allegations;
(D) is generally a face-to-face contact between Licensing staff and the individual who may have relevant information. When an individual's comments and signature are documented on Form 07LC080E, Licensing Services Supplemental Information, a copy is provided to adult interviewees. A copy is not provided to the operator. All interviews are maintained in a confidential manner;
(E) is usually conducted in private and with one individual at a time. An exception may be made when:
(i) a witness accompanies Licensing staff;
(ii) the parent requests to be present when the child is interviewed; or
(iii) an individual chooses to have his or her attorney present;
(F) may be conducted outside of the facility when:
(i) the director is uncooperative;
(ii) an on-site interview places the interviewee at risk; or
(iii) information must be gathered prior to discussion with the operator. Interviews with individuals outside of the facility are documented on Form 07LC080E, Licensing Services Supplemental Information, with a copy provided to adult interviewees;
(G) with a child, Licensing staff considers the child's age and verbal ability and, preferably, a witness accompanies 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) DHS Publication No. 05-57, Parent Notification of Child Interview, is provided for parents when a child is interviewed regarding Licensing requirement violations. Documentation of providing this publication to operators is made on Form 07LC080E, Licensing Services Supplemental Information.
(iii) When Licensing staff accompanies CWS as part of a joint abuse and neglect investigation, interviews are conducted by the CWS specialist, per OAC 340:75-3-8.2. Licensing staff documents CWS interviews on Form 07LC080E, Licensing Services Supplemental Information. When applicable, adult interviewee and CWS specialist signatures are obtained and a copy is mailed to the adult interviewee's residence;
(H) of children or parents associated with a family child care home is not conducted at the facility unless approved by the RPM; and
(I) may be conducted at the child's school. However, this location is not preferable and requires parental permission prior to the interview;
(6) facility observations.
(A) When an allegation is associated with a specific time of day, such as early-morning understaffing, the facility visit is conducted at the time the incident is alleged to have occurred. Licensing staff documents observations by citing the specific conditions observed, such as the director refused to allow Licensing staff to view the program's records or there were nine children 2 years of age with one staff.
(B) When investigating a complaint at a facility, a full monitoring visit is not required unless one is due. Staff-child ratios and supervision are checked at each visit and documented on the monitoring checklist. When numerous, repeated, and/or serious non-compliance are observed, a full monitoring visit is conducted; and
(7) obtaining documentary evidence. Documentary evidence includes information, such as a CWS report, medical and local law enforcement records, signed statements, or photographs. When documentary evidence is obtained, it is entered in the case file.
6. Licensing staff procedure for CWS and Child Care Services (CCS) joint investigations.
(1) Whenever possible, Licensing staff accompanies the CWS specialist on the complaint investigation. However, Licensing staff's role and responsibility is to investigate alleged non-compliance of Licensing requirements or the Child Care Facilities Licensing Act. Licensing staff documents the alleged perpetrator's name and address on Form 07LC080E, Licensing Services Supplemental Information.
(2) When the CWS specialist cannot initiate or conclude an investigation within a reasonable time, Licensing staff requests approval from the Licensing supervisor and consults with the CWS supervisor before proceeding with an investigation. A reasonable time is when the CWS investigation involves:
(A) a child in imminent danger or at risk of serious physical harm and is initiated within 24 hours; or
(B) no imminent risk of harm to a child and no injuries alleged, and is initiated no later than 15-calendar days after the report is accepted for investigation.
(3) Licensing staff interviews the alleged victim and his or her parents, usually in the alleged victim's home, following the guidelines in Instructions to Staff # 5(5) of this Section. Licensing staff advises the CWS supervisor of the findings and CWS completes its investigation.
(4) When there is a finding of confirmed or substantiated child abuse or neglect, a copy of the report is provided to the RPM and statewide licensing coordinator or designee.
(5) Following the CWS investigation completion, Licensing staff provides a letter to the operator including the investigation findings and notice of further action, when applicable.
7. After initiating the complaint, Licensing staff continues to make progress in efforts to complete the investigation within 45-calendar days of receipt. Licensing staff discusses and documents extended time frames with the RPM on Form 07LC080E, Licensing Services Supplemental Information. Licensing staff enters the findings on the Licensing database and completes Form 07LC081E, Licensing Complaint Report Summary, using specific, informative, and easy to understand language.
(1) When a non-compliance other than the original complaint allegation(s) is identified, Licensing staff documents the 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 unsubstantiates the specific allegation and documents the new non-compliance. Understaffing is confirmed even when it is in an age group different from the allegation. Refer to (1) of this Instruction to document this circumstance.
(3) Names or identifying information of the complainant, program personnel, children, and the children's families are not included on Form 07LC081E, Licensing Complaint Report Summary.
(4) When CWS conducts a child abuse investigation, Form 07LC081E, Licensing Complaint Report Summary, contains a summary of complaint allegations and findings not disclosing the alleged perpetrator's or victim's identity, but does allow parents to evaluate the program. Descriptors, such as male personnel and 2-year-old female are not used.
(5) Documents:
(A) in the open record include:
(i) Form 07LC081E, Licensing Complaint Report Summary;
(ii) the monitoring summary;
(iii) complaint findings cover letter; and
(iv) Form 07LC037E, Notice to Comply, when applicable; and
(B) in the confidential section include:
(i) Form 07LC012E, Licensing Complaint;
(ii) Form 07LC080E, Licensing Services Supplemental Information; and
(iii) interviews with personnel, children, collateral witnesses, and complainants.
(6) When information regarding a complaint, including complaint allegations, is requested by the public prior to completion of the investigation, Licensing staff explains information regarding the allegation and findings are released after the investigation is complete. After the database is updated, indicating investigation completion, complaint information is available to the public, per OAC 340:110-1-14.
8. CWS notifies the statewide licensing coordinator and a designated assistant licensing coordinator of substantiated heinous and shocking abuse findings.
(1) Upon CWS notification:
(A) the assistant licensing coordinator immediately:
(i) verifies the individual's program association;
(ii) notifies the Licensing staff and supervisor of the substantiated findings; and
(iii) notifies designated CCS state office staff for Oklahoma Child Care Resource and Referral Association director notification; and
(B) Licensing staff:
(i) notifies the facility owner and operator of the findings by email and includes Form 07LC130E, Heinous and Shocking Abuse Notification;
(ii) contacts the program the next business day verifying:
(I) email receipt;
(II) prohibitions for the perpetrator;
(III) understanding of program responsibility, including parent and legal guardian notification; and
(IV) time frame for notifying Licensing of date of parent and legal guardian notification; and
(iii) documents program contacts on Form 07LC080E, Licensing Services Supplemental Information.
(2) If the program does not notify Licensing of parent and legal guardian notification within two-business days after expiration of the 72-hour time frame, Licensing staff contacts the program to verify certified mail notification.
(3) If the program has not notified parents and legal guardians within the 72-hour time frame, Licensing consults with the supervisor and regional program manager for appropriate action.
9. The summary of facts, on CCS letterhead, is approved by the supervisor before it is provided to the program, and indicates the:
(1) documents reviewed. CWS reports are identified as a DHS document; and
(2) total number of individuals interviewed while identifying program relationship, such as parents, personnel, children, and collaterals or other agency personnel. Information provided protects confidentiality of all individuals.
10. The overview is:
(1) used by supervisors and State Office to review how Licensing staff determined the findings. The overview includes the:
(A) number of individuals interviewed and program relationship;
(B) observations regarding the complaint allegations;
(C) documents and records reviewed;
(D) information used to determine the findings; and
(E) explanation of timeframes not within 45-calendar days; and
(2) submitted with the reduction referral, when complaint findings are included in the reason for a star status reduction.
