Parent Child Development Corporation, DAB No. 3235 (2026)

DECISION

Parent Child Development Corporation (PCDC) is a Virginia nonprofit organization that operated Head Start and Early Head Start programs with grants from the Administration for Children and Families (“ACF”).  The Head Start statute requires that a grantee and its federally funded Head Start program meet various program performance standards, including implementation of a system of safety practices that ensure children are kept safe.  The statute also requires the grantee to timely correct deficiencies in meeting those standards or face termination of its Head Start funding.

In this appeal, PCDC challenges an ACF decision terminating PCDC’s grant funding and designation as a Head Start grantee for failing to correct a safety practices deficiency related to the inappropriate release of a three-year-old child in September 2021.1  In a ruling on October 30, 2024, the Board granted summary judgment in part for ACF, concluding that ACF established the existence of the safety practices deficiency based on PCDC’s failure to ensure that all staff follow appropriate practices to keep children safe by only releasing children to an authorized adult.  Dkt. 64 (SJ Ruling) at 1-2, 14-21.  The Board determined, however, that genuine issues of material fact precluded summary judgment for either party on the question of whether PCDC fully and timely corrected the safety practices deficiency.  Id. at 1-2, 21-24.

The Board held a hearing on May 30, 2025, and the parties presented evidence and argument regarding their respective positions on the issue of whether PCDC fully and timely corrected the safety practices deficiency.  For the reasons explained below, we conclude that a preponderance of the evidence substantiates ACF’s claim that PCDC failed to timely correct the safety practices deficiency.  On that basis, we sustain ACF’s decision to terminate PCDC’s grant funding and designation as a Head Start grantee.

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Legal Background

ACF provides Head Start grants to public and nonprofit organizations that develop and operate programs to promote school readiness of low-income children by enhancing their cognitive, social, and emotional development through health, educational, nutritional, social, and other services.  Head Start Act (Act), 42 U.S.C. §§ 9831, 9833.2  A grantee operating a Head Start program must meet certain “performance standards” in the areas of program governance, program operations, and administrative and financial management.  Id. § 9836a(a)(1) (directing the Secretary of Health and Human Services to establish Head Start performance standards and establishing requirements for compliance monitoring); 45 C.F.R. Parts 1301-1304 (specifying Head Start performance standards and procedures for monitoring compliance).

Head Start grantees must, among other things, comply with performance standards governing program operations, including the development and implementation of a system of management to ensure child safety.  See 45 C.F.R. §§ 1302.1, 1302.47(b).3  Specifically, Head Start grantees “must develop and implement a system of management, including ongoing training, oversight, correction and continuous improvement . . . that includes policies and practices to ensure all facilities, equipment and materials, background checks, safety training, safety and hygiene practices and administrative safety procedures are adequate to ensure child safety.”  Id. § 1302.47(b) (emphasis added).  As relevant here, this system of management must ensure that “[a]ll staff and consultants follow appropriate practices to keep children safe during all activities, including, at a minimum . . . [o]nly releasing children to an authorized adult.”  Id. § 1302.47(b)(5)(iv).

The Secretary, through ACF, periodically reviews Head Start programs to determine whether the grantee meets program governance, program operations, financial management, and administrative standards.  See 42 U.S.C. § 9836a(c); 45 C.F.R. § 1304.1.  If ACF determines that a grantee fails to meet applicable program performance standards and requirements, ACF must inform the grantee of “the deficiencies that shall be corrected.”  42 U.S.C. § 9836a(e)(1)(A); see also 45 C.F.R. § 1304.2.  The Act defines “deficiency” to include “a systemic or substantial material failure of an agency in an area of performance that the Secretary determines involves,” among other things, “a threat to the health, safety, or civil rights of children or staff,” “a failure to comply with standards related to early childhood development and health services, family and community

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partnerships, or program design and management,” or “the misuse of funds received under this subchapter.”  42 U.S.C. § 9832(2)(A).

If ACF finds that a deficiency “threatens the health or safety of staff or program participants or poses a threat to the integrity of Federal funds,” ACF shall require the grantee to correct the deficiency “immediately.”  42 U.S.C. § 9836a(e)(1)(B); see also 45 C.F.R. § 1304.2(b).  In practice, ACF requires that deficiencies necessitating “immediate” correction be corrected within 30 days.  See Cmty. Action Agency of Central Alabama (Central Alabama), DAB No. 2797, at 3 (2017).  When a program has one or more deficiencies, ACF will conduct a follow-up review to determine whether the grantee has corrected them.  42 U.S.C. § 9836a(c)(1)(C)(i).

If ACF determines after a follow-up review that a “grantee has failed to timely correct one or more deficiencies,” then ACF may terminate federal funding for the grantee’s programs.  45 C.F.R. § 1304.5(a)(2)(iii); see also 42 U.S.C. § 9836a(e)(1)(C) (“[T]he Secretary shall . . . initiate proceedings to terminate the designation of the agency unless the agency corrects the deficiency.”); Texas Migrant Council, Inc., DAB No. 2880, at 2 (2018) (“A grantee’s failure to timely correct a single deficiency authorizes ACF to terminate funding for its Head Start programs.”).  “To avoid termination, a grantee with deficiencies must fully correct them within the time frame ACF grants.”  Central Alabama at 9.

A Head Start grantee has the right to a hearing before the Board to contest a termination decision by ACF.  See 42 U.S.C. § 9841(a)(3); 45 C.F.R. § 1304.5(b)(1)(iv).  Head Start termination appeals before the Board are governed by 45 C.F.R. Part 16, except as otherwise provided in the Head Start regulations.  45 C.F.R. § 1304.5(b)(1)(iv), (c).

The burdens of proof in a Head Start termination appeal are well-settled:  “ACF must make a prima facie showing (that is, proffer evidence sufficient to support a decision in its favor absent contrary evidence) that it has a basis for termination under the relevant regulatory standards.”  Gulf Coast Cmty. Action Agency, Inc., DAB No. 2670, at 3 (2015) (collecting cases).  ACF’s burden in this context means making a prima facie showing that the grantee:  (i) had at least one deficiency, and (ii) failed to timely correct that deficiency.  St. Martin, Iberia, Lafayette Cmty. Action Agency (SMILE), DAB No. 2982, at 24 (2019).  “If ACF makes this prima facie showing, the grantee must demonstrate by a preponderance of the evidence that it is in compliance with program standards.”  Gulf Coast at 3.  “A grantee always bears the burden to demonstrate that it has operated its federally funded program in compliance with the terms and conditions of its grant and the applicable regulations.”  Id.  “A grantee, moreover, is clearly in a better position to establish that it did comply with applicable requirements than ACF is to establish that it did not.”  Id.  Accordingly, “the ultimate burden of persuasion is on the grantee to show that it was in compliance with program standards.”  Id.

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Case Background

PCDC is a nonprofit corporation that operated Head Start programs at multiple locations in Virginia, including the TC Walker Head Start Center, King William Head Start Center, Little Lighthouse Head Start Center, Middlesex Head Start, New Kent County Head Start, and West Point Smart Start Center.  Dkt. 79, N.C. Decl. ¶ 7.

On Wednesday, September 29, 2021, PCDC released a three-year-old child from the TC Walker location without the child being signed out by an authorized adult.  Joint Appendix (JA) 004.4  The child (whom we will call “T”) was found in the parking lot by his mother at the time of dismissal.  Id.  About an hour after the incident, T’s mother reported the unauthorized release to PCDC by email, stating:

When I arrived at the school to pick up [T] this afternoon he was in the parking lot following another parent and child.  No teachers to be found ...  I didn’t check him out ... I will not be bringing him back!  This is completely unacceptable!

JA 269 (ellipses in original).  T’s mother further objected that “nobody has called me to ensure he is safe or anything,” and again, “This is completely unacceptable!!!”  Id.  T did not return to school for the next two days; yet, no one inquired about his absence, contrary to PCDC’s policy to call the family one hour after an absence.  JA 273.

PCDC’s staff first reached out to T’s mother on Friday, October 1, at 10:50 a.m. in response to her email.  JA 269, 271.  PCDC’s staff spoke with T’s mother by telephone later that day.  JA 278-79 (phone call summary).  During the call, T’s mother “expressed concerns” about her “child being left alone in the TC Walker parking lot” (JA 278) and stated that when she “arrived at the school, her son was following another parent” (JA 279).  T’s mother was only able to identify the other parent by a vague description – “[s]crubs and long blond hair.”  Id.  She confirmed that there were “no teachers in sight” and that she “saw her son enter the parking lot and she called to him.”  Id.

By this time, PCDC’s staff recognized that an inappropriate release had occurred and would need to be reported.  JA 278-79.  PCDC reported the inappropriate release to Virginia Child Protective Services and ACF on October 1.  JA 270, 278-79.

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Video footage inside and outside the building shows staff allowed T to walk out of the building without being released to an authorized adult and without being signed out by his mother.  JA 443 (inside video); ACF Ex. 54 (outside video).  The sign-in/sign-out sheet used by PCDC for T’s class confirms that no one signed him out on September 29.  JA 281.  The outside video shows T running towards a busy parking lot at dismissal, where he abruptly stepped off the curb into the parking lot and ran quickly past another boy and behind a parked car that was starting to back up in T’s direction.  ACF Ex. 54 at 3:32:10 – 3:32:17.  The car stopped as T stepped back onto the sidewalk and continued running to the right before disappearing from view.  Id.  Seconds later, the car resumed backing up and drove away in the direction that T had been running.  Id. at 3:32:28 – 3:32:40.  The video does not show T connecting with his mother.  About 40 seconds after T disappears from view on the video, he reappears walking back up the school walkway with a woman who has a second younger child with her.  Id. at 3:33:00 – 3:33:56.  According to PCDC, this woman is T’s mother, and they were returning to retrieve T’s blanket from his classroom.  JA 276, 279, 289.

From October 13, 2021 to December 2, 2021, ACF conducted a monitoring review of PCDC’s Head Start program following the reported inappropriate release.  JA 001 (deficiency notice).  By letter dated December 20, 2021, ACF notified PCDC that during the monitoring review it had identified a performance deficiency that must be corrected within 30 days.  JA 001-004.  ACF noted that a three-year-old child at the TC Walker location was not released to an authorized adult and was found in the parking lot with another family at dismissal.  JA 004.  ACF found PCDC was not in compliance with 45 C.F.R. § 1302.47(b)(5)(iv) because it failed to “ensure all staff followed appropriate practices to keep children safe during all activities, including only releasing children to an authorized adult.”  Id.

ACF issued the deficiency notice to PCDC on December 21, 2021.  JA 072.  The corrective action period began 72 hours after issuance of the deficiency notice.  Id.  Thus, the 30-day period for PCDC to correct the deficiency ran from December 24, 2021, through January 23, 2022.  Dkt. 74 (Joint Stip.) ¶ 2.

ACF initiated its follow-up review on January 24, 2022.  JA 067-68.  ACF asked PCDC to submit its policies and procedures on releasing children to an authorized adult, along with evidence that it implemented those procedures, trained staff on them, and had a plan or schedule for monitoring the release of children.  JA 067-68, 056-58, 051-52; see also Joint Stip. ¶¶ 3, 6, 9.  ACF also interviewed representatives of PCDC on February 1 and February 4, 2022, regarding the implementation of corrective measures.  JA 107-115 (Feb. 1 meeting notes), 116-123 (Feb. 4 meeting notes); see also JA 344-45 (D. Marquis Decl. ¶¶ 7-8 (authenticating meeting notes)).

On June 28, 2022, ACF initiated termination proceedings against PCDC, alleging that PCDC, as a Head Start grantee under grant no. 03CH011407, did not “ensure all staff

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followed appropriate practices to keep children safe during all activities, including only releasing children to an authorized adult.”  JA 009-010 (termination notice); see also JA 005-008 (program performance summary report).  The termination notice stated that PCDC had a “continuing uncorrected deficiency in the safety practices of the PCDC Head Start program,” and that the “specific grounds as well as the specific findings underlying” the termination decision are explained in the enclosed program performance summary report.  JA 009-10.  The summary report explained that ACF found continuing noncompliance because the “program did not ensure that staff consistently implemented new child release procedures and forms in the classroom and on the bus.”  JA 007.5  The report further stated that ACF “found inconsistency in how staff” used the sign-in/sign-out form and noted that some forms were blank.  Id.  The report also stated that staff were not trained on the new child release procedures and forms.  Id.

Procedural Background

PCDC timely appealed ACF’s termination decision based on the alleged safety practices deficiency.6  The parties subsequently filed and briefed cross-motions for summary judgment.  Dkt. 64, SJ Ruling at 5.  The Board granted summary judgment in part for ACF, concluding that ACF had established the existence of the safety practices deficiency as a matter of law.  Id. at 1-2, 14-21, 24.  In determining that there was no genuine dispute of material fact regarding the existence of that deficiency, the Board explained: 

Here, PCDC’s system for dismissing Head Start students from its classrooms in September 2021 did not ensure that all staff follow appropriate practices to keep children safe, including, at a minimum, only releasing children to an authorized adult.  PCDC’s noncompliance with section 1302.47(b)(5)(iv) was evidenced by the undisputed fact that a three-year-old child was permitted to walk out of PCDC’s building and into a busy parking lot without being signed-out by an authorized adult (or any adult).  Even staff outside the building failed to intervene as T wandered toward the parking lot alone.  Further, none of PCDC’s staff recognized that an inappropriate release had occurred despite the lack of a completed sign-out sheet.  There is no evidence that anyone either reviewed or questioned the incomplete sign-out sheet at the time of the September 29

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incident.  [JA 281]  Indeed, the education manager responsible for supervising T’s class, J.D., stated that she “left for the day believing everything had happened as it should have.”  [JA 276]  Still further, despite an email from T’s mother and T’s subsequent absences, no one at PCDC recognized the threat to T’s health and safety until Friday, October 1.  PCDC’s system neither prevented the unauthorized release of T, nor did it work to timely detect that an inappropriate release had occurred.  In short, PCDC failed to ensure that its staff followed appropriate practices to keep children safe, including, at a minimum, only releasing children to an authorized adult.

Id. at 18-19.  The Board, however, concluded that summary judgment would not be appropriate for either party on the question of whether PCDC fully and timely corrected the safety practices deficiency, and that a hearing would be necessary to resolve that issue.  Id. at 21-24.7 

On November 20, 2024, following a pre-hearing conference, the Presiding Board Member issued a pre-hearing schedule, noting that the sole remaining issue in the case was whether PCDC fully and timely corrected the safety practices deficiency.  Dkt. 68.  The hearing was initially scheduled for March 6, 2025.  Id.  The parties subsequently filed their three-volume Joint Appendix (JA) consisting of their proposed hearing exhibits.  Dkt. 70, 71, 72, 72a (index).  The parties also filed stipulations of undisputed fact.  Dkt. 74.  The parties submitted written direct testimony for each of their respective witnesses in the form of declarations.  ACF included declarations for its three witnesses in the Joint Appendix.  JA 335-41 (M. Calhoun), 342-43 (D. McConney), 344-45 (D. Marquis).  ACF filed an additional declaration for its primary witness, Melissa Calhoun.  Dkt. 82 (M. Calhoun).  PCDC filed declarations for each of its five witnesses.  Dkt. 75 (K.A. Decl.), 76 (P.B. Decl.), 77 (T.B. Decl.), 78 (D.J. Decl.), 79 (N.C. Decl.).  Both parties filed motions in limine to exclude certain evidence and arguments.  Dkt. 83, 85, 86, 97.

The hearing was rescheduled for May 30, 2025, at the request of ACF due to the unexpected (temporary) unavailability of its primary witness.  Dkt. 94, 98.  The Presiding Board Member admitted into evidence the Joint Appendix, except for certain material excluded by the Board’s Ruling on Motions in Limine (Dkt. 96).

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Hearing Transcript (Tr.), Dkt. 104a, at 12.8  The Board also denied a late-filed motion by ACF to add a new exhibit to the Joint Appendix.  Dkt. 100, 103.   

The hearing was held by videoconference on May 30, 2025, primarily for purposes of cross-examination and rebuttal of the parties’ respective witnesses.9  The hearing was transcribed, and each party received a copy of the transcript and an opportunity to note any transcription errors.  Dkt. 104, 104a.  Both parties submitted post-hearing briefs.  See Dkt. 105, ACF’s Post-Hearing Brief (ACF Br.); Dkt. 106, PCDC’s Post-Hearing Brief (PCDC Br.); Dkt. 107, PCDC Reply Brief (Reply); see also 45 C.F.R. § 16.11(e).

Analysis

1. PCDC failed to satisfy its burden of showing that it fully and timely corrected the safety practices deficiency under 45 C.F.R. § 1302.47(b)(5)(iv).

When, as here, ACF has made the requisite prima facie showing that it has a basis for termination under the applicable legal standards, then “the Head Start grantee ‘must demonstrate by a preponderance of the evidence’ that it was ‘in compliance with program standards.’”  Centro de Servicios a la Juventud, Inc., DAB No. 3095, at 20 (2023) (quoting Friendly Fuld Neighborhood Ctr., Inc., DAB No. 2121, at 3 (2007)).  “In this context, that means that the grantee must demonstrate that it corrected any program deficiencies within the timeframe set by ACF.”  Id.  “[A] grantee must correct its deficiencies to the point of full compliance with the requirement(s) at issue to avoid termination.’”  Texas Migrant Council at 12 (quoting Central Alabama at 8).

Here, “the inappropriate release of T was a manifestation of PCDC’s failure to ensure that its staff follow appropriate practices to keep children safe, including only releasing children to an authorized adult.”  SJ Ruling at 21.  Indeed, “the deficiency lies not in any individual incident or condition, but in the underlying problems in structures, systems or operation that permitted the incident or condition to occur . . . .”  Texas Migrant Council at 15 n.13.  Accordingly, “[t]he Board evaluates the correction of a deficiency not by whether the specific actions or incidents underlying the deficiency were repeated but whether the underlying conditions that caused the deficiency to occur have been eliminated.”  Id. at 15; see also S. De. Ctr. for Child. & Fams., DAB No. 2073, at 33 (2007) (“‘Addressing a specific manifestation and not the structural or systemic problem that permitted it to flourish does not amount to correction of the deficiency.’” (quoting First State Cmty. Action Agency, Inc., DAB No. 1877, at 78 (2003))).

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ACF contends that PCDC failed to fully and timely correct the safety practices deficiency because PCDC failed to:  (i) inform all staff about the facts and circumstances of the inappropriate release incident; (ii) educate and train staff about what was needed to prevent future incidents; and (iii) implement revised procedures to prevent future incidents.  ACF. Br. at 1, 6-11.

PCDC argues that the record evidence shows that it “fully and timely corrected any noncompliance,” and that its “corrective measures removed the underlying conditions” that resulted in the inappropriate release.  PCDC Br. at 3.  Regarding corrective measures, PCDC contends that its training was appropriate and adequate; that it implemented an adequate plan for dismissal at the TC Walker location;10 that it implemented updated release procedures at all sites; and that it fully implemented the new procedures despite the way parents completed the sign-out forms.  Id. at 4-9.

We find that PCDC did not establish, by a preponderance of the evidence, that it fully and timely corrected the safety practices deficiency identified by ACF.  Specifically, the record evidence fails to show that PCDC developed and implemented a comprehensive system of management, including ongoing training, oversight, correction and continuous improvement, adequate to ensure that all staff follow appropriate practices to only release children to an authorized adult.  Accordingly, we conclude that PCDC did not meet the regulatory requirement to ensure child safety through effective management practices and procedures as mandated by 45 C.F.R. § 1302.47(b)(5)(iv).

1. PCDC failed to notify its staff about the inappropriate release incident at the TC Walker location, identify the root cause of the incident, or develop a corrective action plan in response to the incident.

When ACF interviewed PCDC’s staff in February 2022, after the corrective action period, it was evident that PCDC had not identified the “root cause” of the inappropriate release incident at the TC Walker location.  JA 109.  When asked about the root cause, PCDC’s executive director stated that she was “not sure how the child got [past] the teacher” and speculated that “T saw mom coming.”  Id.  But that explanation is patently false – there is no evidence that T left the building because he saw his mother coming.  The video evidence plainly shows T walking out the door and wandering around by himself, long before he connects with his mother (off camera) in the parking lot several minutes later.  See supra at 4-5.     

Even at the hearing, none of PCDC’s witnesses provided an adequate explanation about how the inappropriate release occurred.  PCDC offered testimony from its Education

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Manager who is responsible for supervising Head Start classroom teachers, monitoring classroom compliance, planning and facilitating staff training, and creating and revising PCDC’s policies and procedures.  Dkt. 79, N.C. Decl. ¶ 8.  When asked about her knowledge of the inappropriate release, the Education Manager provided only a vague assertion about the child’s name being called:

All I can tell you is that apparently a child was called by a teacher assistant that worked there at the time that a parent, their parent was there.  And they were dismissed by the substitute at the time . . .  The child was released once they were, their name was called.  After that I was, we were told after – well, it was reported that the child was not released properly.

Tr. at 78-79.  No witness explained why the child’s name was called when the mother was not “there” as the outside video clearly showed.  Nor was there any explanation about why PCDC assigned a substitute to release the children, when a substitute may not be familiar with the children or their parents.  No explanation was provided about why staff were not consistently using the sign-in/sign-out forms.  JA 281 (showing that T was not signed out, and drop-off and pick-up times for other children were not recorded).  No witness explained why PCDC did not have a system in place to ensure that all staff (including substitutes) can only release children to an authorized adult.

In response to further questioning about how the Education Manager became aware of the inappropriate release incident, the Education Manager testified that PCDC’s managers and ACF representatives had a virtual meeting in response to the inappropriate release a few days after it had occurred.  Tr. at 81-83.  But after that meeting, management did not inform PCDC’s staff about the circumstances that led to the inappropriate release.  Tr. at 83.

The lack of information provided to staff was confirmed in further questioning of other PCDC witnesses.  For example, T.B., a teacher assistant at PCDC’s TC Walker location, who helped T retrieve his blanket shortly after the inappropriate release, testified that she knew there was an inappropriate release but did not know how it happened:

Q:     Now you’re aware of an inappropriate release that occurred at T.C. Walker in September of 2021, is that correct?

A:    Yes.

Q:      And how did it happen?

A:      That I don’t know, to be honest with you.

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Tr. at 111.  While T.B. was not directly responsible for dismissing T’s class, she clearly was involved in dismissal at PCDC’s TC Walker location and even assisted T with the retrieval of his blanket following his inappropriate release.  Tr. at 112; JA 276, 280, 289.  It is deeply troubling that someone in that position, who was in close proximity to the inappropriate release incident when it occurred, still cannot explain how it happened.

Teaching staff at other PCDC locations likewise had no information about the circumstances that led to T’s inappropriate release.  K.A., the lead Head Start teacher at PCDC’s Middlesex location since August 2018, testified as follows:

Q:    Are you aware of an incident of unauthorized release occurring at PCDC in September 2021?

A:    I don’t know much about it.

Q:     Do you know how it happened?

A:      No.

Tr. at 117.  Indeed, none of PCDC’s witnesses explained how the inappropriate release occurred.

PCDC argues that it was not required to disclose the circumstances that led to the inappropriate release to staff because the Head Start regulations only require the disclosure of such information on a “need-to-know basis” to the organization’s governing body and policy council.  Reply at 3 (citing 45 C.F.R. § 1302.102(b)(2)).  While the governing body and policy council are certainly required to participate in oversight and correction, the regulations do not restrict the disclosure of such information to the board and policy council.  In fact, the regulation that PCDC cites, which pertains to annual self-assessments, affirmatively requires that the program “[c]ommunicate and collaborate with the governing body and policy council, program staff, and parents of enrolled children . . . .”  45 C.F.R. § 1302.102(b)(2)(ii) (emphasis added).

The importance of information-sharing between management and staff was highlighted in the testimony of ACF’s primary witness, Melissa Calhoun, who provided testimony about the “critical” need for Head Start programs to inform their staff about the circumstances that led to a safety incident, such as the inappropriate release at the TC Walker location.  JA 337 (¶ 9).11  Ms. Calhoun served as a program specialist for the Office of Head Start and has more than two decades of experience as a program specialist, grants management specialist, and monitoring lead.  JA 335 (¶ 1).  She has

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extensive experience developing requests for information from Head Start recipients, conducting interviews with recipients, evaluating information received from recipients, and drafting monitoring reports.  Id.  Ms. Calhoun was personally involved in both the initial and follow-up reviews of PCDC.  JA 336 (¶¶ 3-4).  During the hearing, Ms. Calhoun was cross-examined at length by PCDC’s counsel.  Tr. at 35-70.  Her testimony was candid, forthright, and credible.  She answered questions directly and offered thoughtful and cogent responses, reflecting her many years of experience as a Head Start program specialist.

Ms. Calhoun credibly explained that “child safety is everyone’s responsibility,” and it is important for staff to know the circumstances that led to an inappropriate release “so that they understand and participate in the root cause analysis of the child [release] incident and can identify the risks in their own classrooms/centers and mitigate those risks with appropriate strategies.”  JA 337-38 (¶ 9).  Such information sharing is necessary, she explained, so that management and staff can work together “to ensure that the inappropriate release does not reoccur” and to “devise effective solutions that correct the problem.”  JA 338 (¶ 9).  We find the truth of this testimony to be self-evident.  If teachers and staff within a Head Start program are not informed of the facts and circumstances that led to an inappropriate release, it is unclear how those same employees could identify and correct the same or similar circumstances in their own classrooms to prevent a reoccurrence.  PCDC’s failure to identify, disclose, and discuss the root cause of the inappropriate release incident with its teaching staff undermines PCDC’s contention that it corrected the safety practices deficiency and satisfied the requirement that it have a system in place to make continuous improvements to the organization’s safety practices and procedures.  See 45 C.F.R. § 1302.47(b).

PCDC asserts that it had “various valid reasons” not to disclose the details of the inappropriate release to staff who were “not involved with the incident” or would not be “responsible for developing a corrective action plan.”  Reply at 3-4 (discussing privacy and employment concerns).  This is not a valid defense or explanation.  First, information about the facts and circumstances that led to the inappropriate release could have been disclosed to staff without revealing the identities of the child, parent, and specific staff members involved.  Second, PCDC never developed a corrective action plan.  JA 109.  When ACF asked about a corrective action plan at the follow-up review, PCDC’s executive director responded:  “We did not have time to create an official action plan.  We sat down to put a plan together.  Didn’t have time to put it on a form.”  Id.  Thus, PCDC’s management not only failed to share information about the inappropriate release with PCDC’s staff, but also failed to develop a corrective action plan for staff to review and implement in light of the inappropriate release.   

PCDC also argues that it was not necessary to inform staff about the details of the inappropriate release because “management later notified staff about updates in the dismissal procedures through training and meetings conveying what staff needed to do to

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avoid similar incidents in the future.”  Reply at 3 (citing PCDC Br. at 4-5).  We address and reject those contentions for the reasons explained below.

2. PCDC failed to adequately educate and train staff to prevent future inappropriate release incidents.

At ACF’s follow-up interview of PCDC on February 1, 2022, PCDC’s executive director reported that the corrective measures it implemented included:  (i) “training for teachers” on November 2, 2021; and (ii) creation of a website “for professional development related to supervision and release.”  JA 109.  PCDC provided very little information to ACF about either of these alleged corrective measures, and the limited information provided was conclusory, uncorroborated by training documentation, and lacked specific details about the way PCDC improved its release procedures to ensure that children are only released to an authorized adult.

Regarding the alleged “training” on November 2, 2021, PCDC’s Education Manager admitted during a follow-up review that this activity “was a staff meeting more than a training.”  JA 121.  Notably, none of the topics on the agenda for that “staff meeting” mentioned the September 2021 inappropriate release, dismissal procedures, use of sign-in/sign-out forms, or the release of children to authorized adults.  JA 155.  In describing what was shared with staff at the November 2021 meeting, the Education Manager reported:  “We covered various topics, properly hand children off to them, ensure they are the appropriate people to accept, properly have documentation to sign in/out to parents.”  JA 111.  The Education Manager testified that at this meeting she “touched on active supervision, again, being mindful, and aware of, you know, students, where they are at all times during the course of the day . . . specifically in the classroom setting.”  Tr. at 84.  She mentioned reminding staff about “properly signing children in and out during the course of the day,” and making sure that “authorized individuals . . . are picking their children up.”  Id.  Although ACF requested documentation regarding this purported “training” (JA 111), ACF received no documentation to corroborate the general and conclusory statements about the “various topics” allegedly covered at the meeting.  Tr. at 67-68.

While PCDC eventually revised its drop-off and pick-up procedures and sign-in/sign-out form in January 2022 (JA 126-127, 178), staff were not trained on these materials at the November 2021 staff meeting because the revised materials did not yet exist.  JA 111 (Education Manager admitting that staff were not trained on the new form at that time).  When asked if there was a special training on using PCDC’s revised sign-in/sign-out form, the Education Manager did not identify any such training apart from vague assertions about the November 2021 staff meeting (before the revisions).  Tr. at 96.  PCDC’s failure to present evidence that its teaching staff received specific training on the revised dismissal procedures and new sign-in/sign-out form in January 2022 further demonstrates that the safety practices deficiency was not fully and timely corrected.  See,

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e.g., Centro de Servicios at 34 (concluding that governance deficiency remained uncorrected where Head Start program failed to show that all members of board of governors received relevant and sufficient training during the corrective action period).

Regarding the professional development webinars that PCDC made available to its staff, none of the webinar titles indicate that they relate to specific training on effectuating the appropriate release performance standard.  JA 157, 159-60.  ACF submitted documentation showing that in January 2022 several staff members viewed a webinar entitled “Leave No Child Unattended,” which included instruction about using “active supervision” to keep children safe.  JA 161-68.  PCDC’s Education Manager admitted, however, that this webinar did not concern how to release a child to an authorized adult.  Tr. at 101.  While “active supervision” is certainly one component of any safe dismissal procedure (Tr. at 60, 102), there is no evidence that the webinar provided specific training on effectuating appropriate release procedures at PCDC facilities or on any new procedures that PCDC purportedly implemented after the inappropriate release incident.12 

PCDC also points to an “Active Supervision Toolkit” (developed by ACF) that it used as training material for its staff.  JA 170-77.  The handout discusses the use of active supervision strategies, which “requires focused attention and intentional observation of children at all times,” so that no child is left unattended.  JA 170.  However, PCDC was not cited for the failure to supervise under 45 C.F.R. § 1302.90(c)(1)(v), but for the failure to ensure that its staff only release children to an authorized adult under 45 C.F.R. § 1302.47(b)(5)(iv).  As Ms. Calhoun noted, the seven-page active supervision handout primarily focused on strategies for supervising children throughout the day and did not specifically address how children are to be released to an authorized adult.  Tr. at 59-60 (“So, this to me was active supervision training and not training on release to an authorized adult or what should occur for that process, so that teachers were ready to ensure that the child was only released to the authorized adult.”).  The handout does stress the importance of two-way communication with families about a Head Start program’s policies and procedures, including expectations for pick-up and drop-off.  JA 174.  However, Ms. Calhoun correctly noted that the handout does not purport to train staff on how to implement the dismissal process, define who is responsible for specific procedures at dismissal, train staff on the use of sign-in/sign-out forms, or provide any other critical details to ensure a child is only released to an authorized adult.  Tr. at 60.

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PCDC further argues that its staff received training through another video entitled “School Dismissal Confusion” about an unauthorized release at an elementary school.  JA 159-60; PCDC Br. at 5.  PCDC’s Education Manager noted that the video “wasn’t a webinar per se,” but a “news clip” – and “not a long clip” – that was viewed and subsequently discussed by staff.  Tr. at 99, 101.  PCDC did not show which of its staff viewed and discussed the video and could not say whether all PCDC staff had watched the video.  Tr. at 100 (Education Manager admitting that she could not remember whether all staff had watched the “dismissal confusion” video).  Moreover, PCDC’s Education Manager conceded that the video did not address how a child should be released to an authorized adult or provide any specific training on appropriate release procedures.  Id. at 100-101.

We find that the vague and conclusory statements by PCDC’s witnesses about education and training received by staff before or during the corrective action period (consisting of a single staff meeting and information about active supervision) are insufficient to establish that PCDC fully and timely corrected the safety practices deficiency.  The record evidence does not show that PCDC fully implemented a system of management that included ongoing training, oversight, correction, and continuous improvement to ensure that all staff follow appropriate practices to only release children to an authorized adult as required by 45 C.F.R. § 1302.47(b)(5)(iv).

3. PCDC failed to show that it successfully implemented new post-incident procedures or oversight.

During ACF’s follow-up interview of PCDC on February 1, 2022, PCDC’s executive director stated that one of the corrective measures PCDC implemented was the development of a new “universal” sign-in/sign-out form for all PCDC locations.  JA 109.  PCDC’s Education Manager added that the new form required the printed name and signature of the authorized adult, rather than a description like “mom” as previously accepted.  Id.; see also Tr. at 90-91 (Education Manager testifying about ensuring that teachers get “proper signatures like they’re supposed to” and not allow parents to only “write mom or dad”).

The record, however, does not show that PCDC successfully implemented use of a new “universal” sign-in/sign-out form at all Head Start locations by the end of the corrective action period (January 23, 2022).  The Education Manager testified that she collected the daily sign-in/sign‑out forms from each Head Start teacher for review on a monthly basis.  Tr. at 89-90; see also JA 121 (PCDC’s executive director asserting that the Education Manager “receives all sign in/out at the end of the month to review”).  While PCDC submitted some examples of sign-in/sign-out forms completed at certain locations on various dates in January and early February 2022 (JA 186-247), it appears the only complete month of sign-in/sign-out forms submitted for any Head Start location was for

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one of the two classrooms at the TC Walker location.  JA 213-29 (classroom 1).  Notably, the TC Walker location first used the revised form on January 31, 2022, but only in one of two Head Start classrooms.  JA 229 (classroom 1), 242 (classroom 4).  The examples that PCDC provided for other Head Start locations plainly showed that not all of them were using the January 2022 revised form, even after the corrective action period.  See, e.g., JA 187-200, 202, 208-09, 230-42 (showing continuing use of old form).  Indeed, most of the forms in the record are the old version.  Id.   

Still further, contrary to the Education Manager’s assertion that PCDC no longer allowed the use of descriptions such as “mom” in place of printed names and signatures, many of the sign-in/sign-out forms (both during and after the corrective action period) are missing the required signatures and printed names of authorized adults.  See, e.g., JA 186-95, 200, 202, 231-37.  Additionally, many of the forms are missing time entries for dismissal.  See, e.g., JA 186-95, 198, 201-02, 210-12, 220, 234-35, 238-39, 241, 247.  The wide-ranging inconsistencies on the completed sign-in/sign-out forms (across multiple PCDC locations) demonstrate that PCDC was unable or unwilling to implement its stated corrective action of obtaining sign-out signatures on the new form and did not adequately train staff on proper use of the forms.  Dkt. 82, Calhoun Decl. ¶ 28.  Additionally, the generic titles on the forms do not provide enough information for PCDC to verify that the relative or parent picking up the child is on the child’s list of authorized adults.  Id.

The Head Start teacher at PCDC’s Middlesex location confirmed that she did not always obtain signatures of authorized adults at dismissal and, if the adult was distracted or forgot to sign, she would write “mom” or “dad” on the form to identify who picked up the child.  Tr. at 115-16.  The teacher stated that she generally did not indicate on the form that she (rather than a parent) had written “mom” or “dad” on the form.  Tr. at 117-18.  The teacher admitted that the dismissal procedure described in her written direct testimony (Dkt. 75, K.A. Decl. ¶ 15) was not the procedure used in January 2022 (which included the time immediately after the corrective action period) and she did not recall the precise dismissal procedure used at that time.  Tr. at 114-15, 120-21, 123-25 (recross).  Notably, the written procedure for the Middlesex location states that children “arriving by bus and car during typical arrival and dismissal times are not signed in or out because they are accounted for” using other methods.  JA 128; Tr. at 123-24.  This evidence contradicts PCDC’s assertion that it implemented a “universal” sign-in/sign-out form across all Head Start locations and trained staff on the new form and dismissal procedures.

The Head Start teacher at PCDC’s Mathews/Little Lighthouse location similarly testified that parent signatures were sometimes not obtained at dismissal.  Tr. at 130 (testifying that “every once in a while, one gets past you”).  The teacher explained that parents sometimes “forget to sign their child out,” and staff may forget to obtain a signature because they have “a lot going on” at dismissal.  Id.  The teacher testified that if she did not see or remember who picked up a child, she would call the child’s parent or caregiver

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(after dismissal) for confirmation to complete the sign-out sheet.  Tr. at 130-31.  Even more troubling, the teacher acknowledged that the teaching assistant for her class might not know the identity of the adult to whom she released the child.  Tr. at 132-33 (“But sometimes, if it was somebody that she’s not real familiar with, she might not remember their name or something.”).  While the witness claims that such an incident “hasn’t really happened too often,” id., the fact that it happens at all shows that PCDC does not have a system to ensure that children are only released to an authorized adult and has not fully corrected the safety practices deficiency.   

PCDC argues that its submission of sign-in/sign-out sheets is not “incomplete” and does not show a failure to implement its new procedures because, as the Board determined on summary judgment, ACF did not request a “complete set” of the forms.  PCDC Br. at 7.  PCDC, however, was never limited to presenting only evidence that ACF requested and misunderstands the Board’s summary judgment ruling.  The Board’s review of the evidence on summary judgment is governed by a different review standard.  See SJ Ruling at 4 (explaining that in considering whether there is a genuine dispute of material fact the Board is required to view the record in the light most favorable to the non-moving party and draw all reasonable inferences in favor of the non-moving party); see also Avoyelles Progress Action Comm., Inc., DAB No. 2559, at 3 (2014) (same).  Regardless of what ACF requested immediately following the corrective action period, PCDC had ample opportunity to assemble its appeal file, including all relevant sign-in/sign-out sheets, to demonstrate consistent compliance with its revised procedures and the appropriate release performance standard.  PCDC also had ample reason to do so, given that PCDC bore the burden of demonstrating “by a preponderance of the evidence that it is in compliance with program standards.”  See Gulf Coast at 3.  PCDC has not met that burden for the reasons explained above.

The record evidence is also insufficient to establish that PCDC exercised the necessary oversight to ensure that all staff follow appropriate practices to keep children safe, including only releasing children to an authorized adult.  During the follow-up review, ACF noted the absence of a written monitoring plan from PCDC despite ACF’s request for one.  JA 121-22.  At the hearing, the Education Manager testified that she monitored monthly the use of sign‑in/sign‑out forms by staff and would notify staff of any problems she identified in the way the forms were completed.  Tr. at 90-92.  While she testified that during the relevant time period she gave this feedback to staff “mainly through email,” Tr. at 91, no examples of such feedback appear in the record despite the many examples of improperly completed sign-in/sign-out forms.  See supra at 16.

The Education Manager further testified that PCDC’s management would conduct monitoring reviews of all seven Head Start classrooms two to three times per month, using forms that monitored, among other things, the proper signing in and out of students.  Tr. at 92-94 (discussing monitoring form at JA 295).  The record, however, contains only three monitoring sheets for three Head Start classrooms.  JA 295, 297-98 (documenting

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reviews at West Point II, Middlesex, and Mathews).  PCDC provided no documentation showing that all Head Start locations were monitored or that more than one monitoring review was conducted at any PCDC location before, during, or after the corrective action period.  Moreover, PCDC’s Health and Safety Coordinator, who completed two of the three monitoring reviews (JA 297-98), acknowledged that she did not observe the dismissal process because she conducted her review earlier in the day.  Tr. at 107-08.

PCDC’s Health and Safety Coordinator also provided written direct testimony that she completed separate monitoring screenings, on a quarterly basis, at all Head Start locations using a different, multi-page, Head Start form.  Dkt. 76, P.B. Decl. ¶ 6; Tr. at 106-08.  The record, however, does not include copies of any quarterly monitoring report for any Head Start location.  Tr. at 107-08.  We are unable to discern whether any of these quarterly screenings evaluated compliance with the appropriate release performance standard or whether PCDC’s Health and Safety Coordinator made any determination about PCDC’s compliance with appropriate release procedures based on any quarterly monitoring screening.

2. PCDC’s remaining arguments provide no basis to reverse ACF’s termination decision.

During the hearing and in its post-hearing brief, PCDC attempts to blame ACF for not making PCDC’s leadership aware of the right to request an extension of the corrective action period.  PCDC Br. at 7-8; Tr. at 39-40, 42-43, 49.  ACF, however, had no obligation to advise PCDC’s leadership of the right to request an extension of the 30-day corrective action period.  Cf. Avoyelles at 10 (stating that nothing in Head Start Act “indicates that a failure by ACF to provide adequate technical assistance” can be a basis for excusing noncompliance).  In any event, PCDC’s leadership was fully aware of the right to request an extension, because it did so in response to the earlier deficiency notice it received pertaining to the procurement deficiency.  See SJ Ruling at 7.

PCDC also argues that ACF allowed PCDC to continue operating as a Head Start grantee during the appeal process and permitted PCDC to continue operating as an interim grantee until September 30, 2025.  PCDC Br. at 9-10.  PCDC contends that if ACF were “genuinely” concerned that PCDC did not correct the safety practices deficiency then it would have suspended “PCDC’s funding until PCDC demonstrated its ability to comply.”  Id. at 9.  We reject this argument because it calls for speculation and is factually and legally unsupported.  As PCDC acknowledges, a Head Start grantee is generally allowed to continue operating and receiving funding while it appeals a termination decision.  Id. at 9 (citing 42 U.S.C. § 9841(a)(3)(A)); see also 45 C.F.R. § 1304.5(c)(2).  Moreover, the only issue before the Board is whether PCDC fully and timely corrected the safety practices deficiency within the time frame ACF granted.  See Central Alabama at 9-10.  That corrective active period ended as of January 23, 2022, and to uphold ACF’s termination decision, we need not decide whether PCDC remained out of compliance for

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the duration of this appeal.  See Cent. Miss., Inc., DAB No. 2757, at 24 (2016) (“[P]lans to correct, or even accomplished correction, after the time for correction has expired . . . is not a basis for reversing a termination.”).  Resolution of that question is not relevant to our decision, and we will not engage in speculation about why ACF did not end PCDC’s Head Start funding before September 30, 2025.

Conclusion

We uphold ACF’s decision to terminate PCDC’s status as a Head Start grantee under grant no. 03CH011407 because a preponderance of evidence establishes that PCDC failed to fully and timely correct the safety practices deficiency.