Trinity Lutheran School

2.219.B.1 · At the time of admission, the parent(s)/guardian(s) must provide for each child entering the center: Documentation of school-required immunization status or certificate of medical or nonmedical exemption, is required by the Colorado Board of Health. Up-to-date school-required immunizations must be documented as specified on the Colorado Department of Public Health and Environment certificate of immunization or on an “approved alternate” Certificate of Immunization, defined in Colorado Department of Public Health and Environment rules located in 6 CCR 1009-2 rule section VI(A), (May 15, 2023), no later editions or amendments are incorporated. These regulations are available from the Colorado Department of Public Health and Environment at no cost at www.sos.state.co.us/CCR. These regulations are also available for public inspection and copying at the Colorado Department of Early Childhood, 710 S. Ash St., Bldg. C, Denver, CO 80246, during regular business hours. Colorado law requires proof of immunization status or exemption be provided prior to or on the first day of admission.

Reviewed four children files. Two children files to be missing Colorado department of public health immunization form. Correction: At time of admission, parents must provide documentation of child immunization status or exemption. Up to

2.230.C.8 · All outdoor play areas used for children’s activities must be checked daily and kept safe and free from hazardous materials or debris by removal of debris, dilapidated structures, and broken or worn play equipment. The staff must identify hazardous, high-risk areas; those areas must be made inaccessible to children to reduce the possibility of injuries and accidents.

In preschool playground observed a hole in the ground approximately 20 in wide and 4 inches deep. Correction: All outdoor play areas used for children's activities must be checked daily and kept safe and free from hazardous materials or debris by removal of debris or any broken items. Correct Immediately. Document compliance to licensing specialist with written response. Correct by 11/10/2025

Corrected by Nov 10, 2025

2.217.A.9 · At least one (1) staff member with the current Department-approved medication administration training and delegation must be on duty at all times.

Reviewed three staff files. Annie N, Charlene L, and Kristen L. to be missing department-approved medication delegation training. Correction: At least one (1) staff member with current department-approved medication administration delegation training must be on duty at all times. Correct Immediately. Document compliance to licensing specialist with written response. Correct by 12/11/2024

Corrected by Dec 11, 2024

2.212.N · Prior to working with children, each staff member must read and be trained on the center’s policies and procedures for the administration of medications. Staff members must sign a statement indicating that they have read and have been trained on the center's administration of medications policies and procedures FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed three staff files. Annie N, Charlene L, and Kristen L. to be missing medication administration policy and procedures documentation. Correction: Prior to working with children, all staff must sign a statement, stating they have read and are trained regarding the center's policies and procedures regarding medication administration. Correct Immediately. Document compliance to licensing specialist with written response. Correct by 12/11/2024

Corrected by Dec 11, 2024

2.213.J · Within ninety (90) calendar days of employment, all directors and assistant directors must complete the Department-approved training: Working with an Early Childhood Mental Health Consultant. This course is required once and will be counted towards ongoing professional development.

Reviewed three staff files. Annie N. to be missing department-approved early childhood mental health consultant training. Correction: Within ninety (90) calendar days of employment, all directors and assistant directors must complete a department-approved early childhood mental health consultant training. Document compliance to licensing specialist with written response. Correct by 01/10/2025

Corrected by Jan 10, 2025

2.213.K · Within ninety (90) calendar days of employment, all directors and assistant directors must complete the Department-approved training: Introduction to Child Care Health Consultation. This course is required once and will be counted towards ongoing professional development.

Reviewed three staff files. Annie N. to be missing department-approved introduction to child care health consultation training. Correction: Within ninety (90) calendar days of employment, all directors and assistant directors must complete a department-approved introduction to child care health consultation training. Document compliance to licensing specialist with written response. Correct by 01/10/2025

Corrected by Jan 10, 2025

2.230.B · Indoor and outdoor equipment, materials, and furnishings must be sturdy, safe, and free of hazards.

In playground a ripped and deflated orange basketball accessible to children. Correction: Indoor and outdoor equipment, materials and furnishings must be sturdy, safe and free of hazards. Correct

2.136.A · All child care providers must have a written plan that accounts for children with disabilities as defined in 42 U.S.C. Section 12102 and those with access and functional needs as defined in the State Emergency Operations Plan (2019) (SEOP). The State Emergency Operations Plan (SEOP) is hereby incorporated by reference. No later editions or amendments are incorporated. The State Emergency Operations Plan (SEOP) is available for public inspection and copying at the Colorado Department of Early Childhood at 710 S. Ash St., Bldg. C, Denver, CO 80246 during regular business hours. The State Emergency Operations Plan (SEOP) is also available for no cost from the Colorado Division of Homeland Security & Emergency Management at https://www.colorado.gov/pacific/dhsem/state-eop. The plan must include a specific requirement indicating how all children with special needs will be included in the emergency plan.

Policies and procedures to be missing a written plan that accounts for children with disabilities included in the emergency plan. Correction: All child care providers to have a written plan that accounts for children with disabilities with specific requirements indication how children with disabilities are included in the emergency plan. Correct Immediately. Document compliance to licensing specialist with written response. Correct by 12/11/2024

Corrected by Dec 11, 2024

2.229.C · Items labeled “keep out of reach of children” must be inaccessible to children.

One pack of Kirkland wipes, accessible to children and labeled by the manufacturer as keep out reach of children. Correction: Items labeled Keep out of Reach of Children must be inaccessible to children. Correct immediately. **CORRECTED AT TIME OF INSPECTION, Director removed wipes and made them inaccessible, January 17, 2024. No further response required. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.238.H · Centers must comply with the locally adopted fire code, including but not limited to the following: Every exit must be clearly visible, or the route to reach it must be conspicuously indicated. Each path of escape must be clearly marked.

Two exits in the Kindergarten classroom to not be clearly marked. Correction: Every exit must be clearly visible or the route to reach it must be conspicuously marked. Correct immediately. Document compliance to the Licensing Specialist with the written response. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.120.I · Every five (5) years, all child abuse and neglect inquiry background checks must be renewed by resubmitting an inquiry form and current fee to the Department for processing. An updated clearance letter or verification of the submission of the inquiry form must be obtained before five (5) years from the date reflected on the current clearance letter.

Four staff files reviewed. Mary C to have expired verification of Trails Background Clearance Letter. Correction: Every five years, all child abuse and neglect inquiry background checks must be renewed by resubmitting an inquiry form and current fee. Correct immediately. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Mary C. has reviewed the powerpoint within 24 hours. Submit documentation of Trails clearance letter for Mary C. with written response to Specialist. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.121.D.5 · Every five (5) years, requests for FBI criminal record checks must be renewed by completing the fingerprint process at an approved vendor. An updated clearance letter or verification of the submission of the request FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ must be obtained prior to five (5) years from the date reflected on the current clearance letter.

Four staff files reviewed. Mary C. to have expired documentation of FBI criminal record checks. Correction: Every five years, requests for FBI criminal record checks must be renewed. Correct immediately. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members Mary C has reviewed the powerpoint within 24 hours. Submit documentation of FBI criminal record check for staff members Mary C. with written response to Specialist. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Four staff files reviewed. Charlene W. to have expired documentation of Standard Precautions Training Course. Correction: All staff must compete a Department approved Standard precautions training and renew annually. Correct immediately. Document compliance to the Licensing Specialist with the written response. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.213.G · Within thirty (30) calendar days of employment, all employees and regular volunteers must be trained using a Department-approved training about child abuse prevention, which includes common symptoms and signs of child abuse, how to report, where to report, and when to report suspected or known child abuse or neglect. This training must be renewed annually.

Four staff files reviewed. Mary C., Kristen L., Annie N., Charlene W. to have expired documentation of completed training course about child abuse prevention. Correction: All employees must be training using a Department approved training about child abuse prevention. Correct immediately. Document compliance to the Licensing Specialist with the written response. Correct by 01/17/2024

Corrected by Jan 17, 2024

2.213.M · All staff who work with children must complete a minimum of fifteen (15) clock hours of ongoing professional development each year, beginning with the start date of the employee. At least three (3) clock hours per year must be in the focus of social-emotional development.

Four staff files reviewed. Mary C., Kristen L., Annie N., and Charlene W. to be missing documentation of a minimum of 15 clock hours of ongoing professional development each year. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: All staff who work with children must complete a minimum of 15 clock hours of ongoing professional development each year. Send a plan of compliance to the Licensing Specialist with the written response. Correct by 02/16/2024

Corrected by Feb 16, 2024