Oops is now a licensing term

Mike Newall and Craig R. McCoy have an article in The Philadelphia Inquirer:

A seven-year-old Philadelphia boy who drowned in a murky backyard pool in June was enrolled in a day-care center that the state failed to close, even after learning that the operator obtained her license by lying about her extensive criminal record, according to an official investigation into the death. In a "fatality review" obtained by The Inquirer, investigators said Isear Jeffcoat (photo) died while the operator, Tianna Edwards, 31, spent the day at the SugarHouse Casino.
Governor Corbett has announced plans to suspend an unspecified number of Department of Public Welfare employees connected with the case.
Edwards was arrested on 18 January by Philadelphia police and charged with involuntary manslaughter and endangering the welfare of a child. She faces a preliminary hearing and is being held on $700,000 bail.
In the scathing official review, investigators detailed the laggardly response of the state when confronted with information that Edwards obtained a state day-care license after using someone else's name and hiding her criminal past. Edwards had convictions in three counties on charges including fraud, theft, forgery, and illegal gun possession, court records show.
The Governor's Office of General Counsel released a statement announcing the planned suspensions after The Inquirer sought comment about the case. Following an initial internal investigation, Corbett ordered the hiring of an outside firm to further examine DPW's handling of the case, the statement said, and "additional personal actions may occur. Protecting children remains a priority of the Corbett administration, and any circumstances that jeopardizes the health and safety of a child will not be tolerated," the statement said. The statement did not say which DPW employees had been suspended.
"Those questions will be addressed when the investigation is completed," said Nils Hagen-Frederiksen, press secretary for the general counsel.
The death review examined Isear's 30 June 2012, drowning while at Tianna's Terrific Tots, a day-care program run by Edwards, who had taken Jeffcoat and twenty other children from her day-care center along Rising Sun Avenue to swim in a filthy, nine-foot inground pool at a private residence on the 6600 block of North Eighth Street, the review said. Shortly after arriving, Edwards left the children and went with another staff member to the casino, according to the report and police sources. The children were left in the care of two adult workers, one of whom had a criminal background that would prohibit him from being licensed to work with children, the review said. There were fifteen children swimming in the pool, with one staff member watching, according to the report.
When Isear did not surface, a worker called Edwards, who returned to look for the boy.
"There are conflicting reports regarding whether some staff members jumped into the pool to look for Isear," the review reads. Such reviews are state-mandated in every child fatality and are conducted by a panel of child welfare experts, including medical professionals and police.
The DPW knew as early as December of 2011 that Edwards had opened her day-care centers under a false identity, the review said. After receiving a report of possible fraud involving Edwards, two officials from the state Office of Child Development and Early Learning met with representatives from the Philadelphia District Attorney's Office, who had recently charged Edwards with an unrelated crime: she allegedly stole her sister's identity to buy and burn a Jaguar for insurance money.
During the 2011 meeting, DPW officials confirmed that Edwards had stolen the identity of her sister-in-law, Nikita Smith, to open the day-care centers.
Although applicants for state day-care licenses are required to obtain fingerprint-based FBI clearances, they are not required to show photo identification when they submit their paperwork, the review said.
In January of 2012, months before Isear's death, the state inspector general opened an investigation into the identity theft. The DPW, at that point, "believed that they were to do nothing further until the investigation by the district attorney and inspector general were completed," the review said.
In April, DPW officials visited Edwards' day-care center along Germantown Avenue, closing it for "site-specific violations", but not for any fraud violations. However, her facility on Rising Sun Avenue was not inspected and continued to operate. It took the death of Isear to trigger the closing of that facility.
According to the report, Isear's mother, a resident of the Tioga section of the city, told investigators that her son had been attending the day-care facility for about six months.
And she indicated to investigators that she knew that Edwards had obtained a license fraudulently. The mother also said she was aware that another child under Edwards' care had died. In 2010, a two-year-old girl lost consciousness at one of Edwards' facilities and later was pronounced dead at Temple University Hospital. Her death was attributed to swallowing a battery, though it was unclear whether it happened while at Edwards' day-care center, the report said. Judging from the severity of the child's internal injuries, she may have ingested the battery a week earlier, a medical examiner said.
Isear's death review team found that the DPW was aware of the earlier death. However, its sister agency in Philadelphia, the Department of Human Services, had no record of the earlier death, the report noted, even though state officials could document contact with the DHS to inform them of the fatality. Said DHS spokeswoman Alicia Taylor: "We did receive a phone call from DPW sometime after the death and are currently investigating how we handled the call."
Among other criticisms of the response to Isear's death, the team reported that it was "astonished" that the state did not require applicants who wished to open a day-care center to provide a photo identification. It also condemned the system for failing to require updated criminal and child-abuse checks as part of the annual reinspecting process. It recommended that the state reconfirm the identity of all holders of licenses in Pennsylvania to operate day-care centers by checking their photo IDs at their next annual inspection.
Court records show that Edwards has a lengthy criminal record and several aliases. She has been convicted in Philadelphia and Bucks and Montgomery Counties for crimes including fraud, theft, and giving false identification to a police officer. At the time of Isear's death, she was on probation in the stolen identity case involving her sister.
According to court documents, Edwards lived in Juniata Park with her young son.

Rico says can you say 'clusterfuck by all concerned'? Some gummint people gotta get burned for this one... (And it's but one of the disadvantages of being poor: getting inadequate child care.)