OUR LADY OF GOOD COUNSEL SCHOOL INFANT AND TODDLER PROGRAM

HAR §17-895.1-55 — TB clearance

The facility has 1 staff member missing a TB clearance. XXXXX Correction: The facility submitted a TB clearance for 1 staff member. XXXXX

HAR §17-895.1-55 — Physical exam clearance

The facility has 1 staff member missing a physical exam clearance. XXXXX Correction: The facility has submitted a physical exam clearance for 1 staff member. XXXXX

HAR §17-895.1-37 — For every group, there shall always be one staff who meets the qualifications of a lead caregiver or caregiver

On November 14, 2025, CCLW observed 2 Aides in the child care area. There was no Lead Caregiver or Caregiver at the facility during the time of the visit. Correction: The Principal submitted a DHS 957 Staff Sequence Form, showing that a qualified Caregiver will be in the Infant Toddler room at all times.

HAR §17-895.1-36 — Staff-child ratio and group size shall be met and maintained during all hours or operation

On November 14, 2025, CCLW observed the following groups of children and staff at Our Lady of Good Counsel School Toddler Program: Toddler Room (15 - 36 months old) - 4 children in care with 2 Aides, not meeting the Staff-child ratio. Correction: The Principal submitted a DHS 957 Staff Sequence Form, showing that a qualified Caregiver will be in the Infant Toddler room at all times.

HAR §17-895.1-35 — Caregiver staff must complete 16 hours annually after the initial training in at least two of the approved topic areas

The facility has 4 staff needing to complete at least 16 hours of ongoing training in at least 2 of the department approved topic areas. XXXXX Correction: The facility has submitted at least 16 hours of ongoing training in at least 2 of the department approved topic areas, to PATCH, for 4 staff members. XXXXX

HAR §17-895.1-12 — Evidence of liability coverage

Our Lady of Good Counsel School Infant and Toddler Program's liability insurance coverage expired on July 1, 2025. Correction: Our Lady of Good Counsel School Infant and Toddler Program submitted liability insurance coverage, which expires on July 1, 2026.

HAR §17-895.1-43 — One caregiver with current certificates during all operating hours; infant CPR when caring for infant children

The Worker reviewed staff records and found that no staff have current pediatric first aid and CPR certification. Correction: The Worker reviewed staff records and found that 6 out 8 staff have current pediatric first aid and CPR certification.

HAR §17-895.1-3 — Background Clearance for Staff

One staff member, A. Quemado must submit to an annual background clearance. Correction: One staff member, XXXXX has submitted to an annual background clearance. Provider is provisionally cleared.

HAR §17-895.1-35 — Staff training, experience, and personal qualifications

The Infant Toddler program does not have sufficient qualified staff. There is no Director and the program only has 1 qualified Caregiver with 3 Aides on the staff listing. Correction: Child Care Licensing Worker (CCLW) N. Brock verified that the facility has a qualified director and sufficient qualified staff.

HAR §17-895.1-55 — TB clearance

Principal: no written evidence of the results of a TB test or a TB risk assessment. Correction: Principal submitted written evidence of the results of a TB test or a TB risk assessment.

HAR §17-895.1-55 — TB clearance

Principal: no written evidence of the results of a TB test or a TB risk assessment. Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-11 — Policy to inform parents in writing of liability insurance

Our Lady of Good Counsel School does not inform the parents and the guardians of their enrolled children in writing of its policy relating to liability insurance. Correction: Liability Insurance is located on page 18 of the policy Handbook.

HAR §17-895.1-35 — All caregivers meet qualifications

On November 13, 2024, Child Care Licensing Worker (CCLW) reviewed the staffing list. CCLW found that: - the only qualified toddler director was on a medical leave of absence - the principal is not qualified as an toddler director - one toddler aide was not listed in the Hawaii State of Department of Human Services Early Childhood Registry. Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-71 — Written fire inspection report documenting fire warning device inspected initially and annually by fire inspector report dated: <date>

HFD Fire Inspection Report, dated 10/26/2023 - expired HFD Fire Inspection Report, dated 11/19/2024: UNSATISFACTORY for the preschool and the toddler program Correction: Director submitted an acceptable Fire Inspection Report dated November 19, 2024.

HAR §17-895.1-35 — All caregivers meet qualifications

On November 13, 2024, Child Care Licensing Worker (CCLW) reviewed the staffing list. CCLW found that: - the only qualified toddler director was on a medical leave of absence - the principal is not qualified as an toddler director - one toddler aide was not listed in the Hawaii State of Department of Human Services Early Childhood Registry. Correction: Child Care Licensing Worker (CCLW) N. Brock verified that the facility has a qualified director and all staff are registered with Hawaii State of Department of Human Services Early Childhood Registry.

HAR §17-895.1-55 — Physical exam clearance

Principal: no written evidence of the results of a physical examination Correction: Medical Report (DHS 984) completed for the Principal.

HAR §17-895.1-3 — Background checks according with chapter 17-801 (criminal history, sex offender registry, child abuse/neglect, adult abuse perpetrator, employment history check, and other information)

Two toddler staff members have not submitted a copy of their employment history records for review. Correction: All staff have submitted a copy of their employment history records for review.

HAR §17-895.1-71 — Written fire inspection report documenting fire warning device inspected initially and annually by fire inspector report dated: <date>

HFD Fire Inspection Report, dated 10/26/2023 - expired HFD Fire Inspection Report, dated 11/19/2024: UNSATISFACTORY for the preschool and the toddler program Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-11 — Policy to inform parents in writing of liability insurance

Our Lady of Good Counsel School does not inform the parents and the guardians of their enrolled children in writing of its policy relating to liability insurance. Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-3 — Background checks according with chapter 17-801 (criminal history, sex offender registry, child abuse/neglect, adult abuse perpetrator, employment history check, and other information)

Two toddler staff members have not submitted a copy of their employment history records for review. Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-55 — Physical exam clearance

Principal: no written evidence of the results of a physical examination Correction: The facility will be unable to correct the deficiency by 06/07/2025.

HAR §17-895.1-41 — Current TB clearance & immunizations, written statement from licensed physician that immunizations pose a threat to the child's health, or religious exemption form

On November 13, 2024, Child Care Licensing Worker (CCLW) reviewed the toddlers' enrollment, emergency, and health records. - Child #1: DHS 908 - parent's signature, missing immunization shot record - Child #2: Hep A - no shots - Child #3: DHS 908 - parent's signature - Child #4: DHS 908 - parent's signature, Hep A (update child's immunization record) - Child #5: DHS 908 missing, immunization record missing - Child #6: DHS 908 - parent's signature - Child #7: DHS 908 - parent's signature, Hep A (update child's immunization record) Correction: Child Care Licensing Worker, N. Brock has reviewed the children's records and them sufficient.