Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
340:110-1-9.2. Complaint investigations
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Revised 7-01-09

 

(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 staff obtains as much relevant information as possible from the complainant.  • 2

(d) Screening complaints.  The 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.  • 3

(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 (CW) or law enforcement.  This does not include weekends and holidays if 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; or
    • (L) failure to obtain background investigations.
  • (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 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 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 OAC 340:110-1-13 is also followed.

(i) Child abuse and neglect complaints.  Upon receipt of a complaint alleging abuse of a child in care, the licensing staff immediately notifies the licensing supervisor and makes a referral to CW.  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 the information 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 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 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.  Facilities may submit a written request for a summary of the facts used to evaluate and determine the licensing complaint findings.  • 7

INSTRUCTIONS TO STAFF 340:110-1-9.2

 

Revised 7-01-09

 

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

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

(2) responding to the concerns of the complainant; 

(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 (CW) for investigation; 

(6) requesting a signed, statement from the complainant when serious violations are involved or a negative sanction 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 are not released to the public until the findings have been determined.  The information requested includes: 

(1) date and time the complaint was received; 

(2) 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; 

(5) specific information regarding the 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) 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) whether the complaint has been discussed with the director.

 

3.   The 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, 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 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, 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 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, the complaint is referred to CW and the decision to accept the referral is made by CW staff. 

(C) Sex play between children is referred to CW 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) of this Instruction 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.  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) 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 not investigated by licensing and is referred to OKDHS Office for Civil Rights.  Licensing staff: 

(A) completes Form 14CR001E, Discrimination Complaint – Client or Vendor, and submits to OKDHS Office for Civil Rights; and 

(B) obtains mailing information and sends a blank copy of Form 14CR001E, Discrimination Complaint – Client or Vendor, to the complainant. 

(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 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, Notice to Comply; 

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

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

 

4.   The investigation generally includes: 

(1) a review of the 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, Licensing Services Supplemental Information, 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; 

(E) with a child, takes into consideration the age and verbal ability of the child, 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) Publication No. 05-57 is provided for parents when a child is interviewed regarding 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 as part of a joint abuse and neglect investigation, interviews are conducted by the CW 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 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‑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.  Form 07LC003E, Monitoring Report – Child Care Center, is used to document any non-compliance observed; and 

(6) obtaining documentary evidence.  Documentary evidence is information that is recorded, such as a CW 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 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. 

(2) If the CW 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 supervisor before proceeding with an investigation.  A reasonable period of time means: 

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

(B) the CW investigation of a report that does not indicate imminent risk of 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 staff interviews the alleged victim and his or her parents, usually in their home, following the guidelines outlined in OAC 340:110‑1‑9.2 Instructions to Staff 4(4)(E).  The licensing staff advises the CW supervisor of the findings, and CW 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 operator to voluntarily cease care or prohibit the alleged perpetrator from any contact with children pending the outcome of the investigation.  The operator is advised of the possibility of an injunction or Emergency Order if the operator refuses and children are considered at imminent risk of harm. 

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

(6) Following completion of the CW 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 indicated.

 

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

(2) When a child abuse investigation has been conducted by CW, Form 07LC081E, contains a summary of 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-year-old female are not used. 

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

(4) 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.   The 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, collateral or other agency personnel.  Information is provided while protecting confidentiality of all parties.  Supervisor approval is necessary before providing the summary to the facility.