2.212.G · All staff members must submit to the center a medical statement, signed and dated by a physician or other health care provider, verifying that they are in good mental, physical, and emotional health appropriate for the position for which they have been hired. This statement must be dated no more than six (6) months prior to employment or within thirty (30) calendar days after the first date of employment. Subsequent self-reported health histories must be submitted annually.

Reviewed four staff files and identified Blaire and Kendra's files missing documentation of medical statements verifying good health appropriate for the position in which they have been hired. Correction: Obtain medical statements for all staff. Correct and respond with a statement of compliance by 3/1/25. Correct by 03/01/2025

Corrected Corrected by Mar 1, 2025

Category: health medication. Marked corrected in the state record.

2.216.B.1.e · There must be at least one (1) staff member on duty in each infant room at all times who holds a current Department-approved first aid and safety certificate that includes cardiopulmonary resuscitation (CPR) for all ages of children. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed four staff files and identified INS Marisol's file missing documentation of a current Department-approved CPR and First Aid training. Observed Marisol alone in the infant room at the time of visit. Correction: Ensure there is at least one staff member on duty in each infant room at all times who holds a current Department-approved CPR and First Aid certificate. Correct immediately and respond with a plan for ongoing compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: recordkeeping. Marked corrected in the state record.

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.

Reviewed four staff files and identified preschool teacher Blaire's file missing documentation of a current Department-approved standard precautions training. Correction: Obtain current Department-approved standard precautions training for Blaire. Correct immediately and respond with verification of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: recordkeeping. Marked corrected in the state record.

2.213.D · Staff working with children less than three (3) years of age must complete a Department-approved prevention of shaken baby/abusive head trauma training prior to working with children less than three (3) years of age. This training must be renewed every two (2) years and will be counted towards ongoing professional development.

Reviewed four staff files and identified preschool teacher Blaire's file missing documentation of a current Department-approved prevention of abusive head trauma training. Observed a child under three years of age in the preschool classroom. Correction: Obtain documentation of a current Department-approved prevention of abusive head trauma training for Blaire. Correct immediately and respond with verification of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: recordkeeping. Marked corrected in the state record.

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ abuse, how to report, where to report, and when to report suspected or known child abuse or neglect. This training must be renewed annually.

Reviewed four staff files and identified preschool teachers Blaire and Kendra's files missing documentation of a current Department-approved training about child abuse prevention. Both staff have been employed for more than 30 days. Correction: Obtain documentation of a current Department-approved training about child abuse prevention for Blaire and Kendra. Correct immediately and respond with verification of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: recordkeeping. Marked corrected in the state record.

2.213.I · Within ninety (90) calendar days of employment, all staff required to register with the Colorado Shines Professional Development Information System (listed in rule section 2.208(D)) must complete the Department-approved Recognizing the Impact of Bias on Early Childhood Professionals training or other Department-approved training on implicit bias. This course is required once and will be counted towards ongoing professional development.

Reviewed four staff files and identified preschool teachers Blaire and Kendra's files missing documentation of a Department-approved training on implicit bias. Both staff have been employed for more than 90 days. Correction: Obtain documentation of a Department-approved training on implicit bias for Blaire and Kendra. Correct and respond with verification of compliance by 3/1/25. Correct by 03/01/2025

Corrected Corrected by Mar 1, 2025

Category: recordkeeping. Marked corrected in the state record.

2.213.H · Within ninety (90) calendar days of employment, all staff required to register with the Colorado Shines Professional Development Information System (listed in rule section 2.208(D)) must complete the Department-approved training course: Introduction to the Early Intervention and Preschool Special Education Programs. This course is required once and will be counted towards ongoing professional development.

Reviewed four staff files and identified preschool teacher Blaire's file missing documentation of the Department-approved Intro to Early Intervention training. Blaire has been employed for more than 90 days. Correction: Obtain documentation of the Department-approved Intro to Early Intervention training for Blaire. Correct and respond with verification of compliance by 3/1/25. Correct by 03/01/2025

Corrected Corrected by Mar 1, 2025

Category: recordkeeping. Marked corrected in the state record.

2.210.A.2 · A record must be maintained, either written or electronic, for each staff member that includes the following: Verification of qualifications and training.

Reviewed four staff files and identified Blaire's file missing verification of qualifications for the position in which she functions. Blaire is the assigned ECT in the preschool classroom. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Obtain verification of ECT qualifications for Blaire. Correct and respond with verification of compliance by 3/1/25. Correct by 03/01/2025

Corrected Corrected by Mar 1, 2025

Category: recordkeeping. Marked corrected in the state record.

2.120.C.1.a.1 · The Trails child abuse or neglect records request must be made on the state-prescribed form, accompanied by the required fee within the following required time frames: Child care centers (less than 24-hour care), school-age child care facilities, family child care homes, and qualified exempt providers must meet the following: Individuals who have obtained a successfully completed CBI or FBI record check may care for children, for no longer than ninety (90) calendar days, while waiting for all other required background checks to be completed. The individual must be supervised at all times by an individual who has successfully completed all required background checks.

Reviewed four staff files and identified Aide Kendra's file missing documentation of a TRAILS clearance letter. Kendra was observed alone with two preschool children completing diaper changes. Correction: All individuals requiring a background check must review 'Navigating the Background Check', the Investigation Unit's (BIU) Webpage powerpoint on the CDEC website. Submit verification (via email) that Director Kathlynn has reviewed the powerpoint within 24 hours. Correct immediately and submit documentation of TRAILS clearance letter for Kendra with written response to Specialist by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: supervision. Marked corrected in the state record.

2.121.J.1 · The following background check requests must be submitted and successfully completed for each state an individual has resided in, in the past five years, prior to an individual caring for children or allowing the individual unsupervised access to children in child care centers (less than 24-hour care), school-age child care facilities, family child care homes, and qualified exempt provider homes: FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed four staff files and identified Aide Kendra's file missing documentation of an out of state clearance letter. Kendra has lived out of state in the last five years. Kendra was observed alone with two preschool children completing diaper changes. Correction: All individuals requiring a background check must review 'Navigating the Background Check', the Investigation Unit's (BIU) Webpage powerpoint on the CDEC website. Submit verification (via email) that Director Kathlynn has reviewed the powerpoint within 24 hours. Correct immediately and submit documentation of out of state clearance letter for Kendra with written response to Specialist by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: supervision. Marked corrected in the state record.

2.213.N · Within thirty (30) calendar days of employment and annually, all staff responsible for the collection, review, and maintenance of the child immunizations records must complete the Colorado Department of Public Health and Environment immunization course.

Reviewed four staff files and identified Director Kathlynn's file missing documentation of the CDPHE immunization course. Kathlynn is responsible for the collection, review, and maintenance of the child immunization records. Correction: Obtain documentation of the CDPHE immunization course for Kathlynn. Correct immediately and respond with verification of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: health medication. Marked corrected in the state record.

2.220.K · Topical preparations such as petroleum jelly, diaper rash ointments, sunscreen, insect repellent, and other ointments may be administered to children with written authorization from the parent(s)/guardian(s). These preparations may not be applied to open wounds or broken skin unless there is a written order by the prescribing health care provider.

Reviewed two children's files and identified both files missing documentation of written authorization for topical preparations. Correction: Obtain documentation of written authorization from parents/guardians to administer topical preparations. Correct immediately and respond with a statement of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: ratio. Marked corrected in the state record.

2.209.A.7 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include: A dated, written authorization for emergency medical care signed and updated annually by the parent(s)/guardian(s). The authorization must be notarized if required by the local hospital, clinic, or emergency health care facility;

Reviewed two children's files and identified both files missing documentation of written authorization from the parents/guardians for emergency medical care. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Obtain documentation of written authorization for emergency medical care from the parents/guardians for all enrolled children. Correct immediately and respond with a statement of compliance by 3/1/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Category: health medication. Marked corrected in the state record.

2.206.A · At the time of enrollment, and upon amendments to policies and procedures, the center must give the parent(s)/guardian(s) the center’s policies and procedures and provide the opportunity to ask questions. Written copies must be available either electronically or in hard copy. The center must obtain a signed document stating that the parent(s)/guardian(s) have received the policies and procedures, and by signing the policies and procedures document, the parent(s)/guardian(s) agree to follow, accept the conditions of, and give authorization and approval for the activities described in the policies and procedures.

Reviewed two child files and identified both files missing a signed document stating the parents/guardians agree to the policies and procedures of the program. Correction: Obtain signed document stating the parents/guardians agree to the policies and procedures of the program for all enrolled children. Correct immediately and respond with a statement of compliance by 1/30/25. Correct by 01/30/2025

Corrected Corrected by Jan 30, 2025

Marked corrected in the state record.

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

The center's perimeter and playground fencing has at least one area where the metal fence posts are more than 4 inches apart, posing a potential entrapment hazard. Correction: Ensure areas between fence posts do not pose an entrapment hazard. Correct and respond with a plan for ongoing compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: physical safety. Marked corrected in the state record.

2.220.F · Staff designated by the director to give medications must complete the Department-approved medication administration training and have current annual delegation or more often as determined by the Department-approved child care health consultant. Delegation must be from the center’s current Department-approved child care health consultant who must observe and document the competency of each staff member involved in medication administration. All staff administering medication must have current cardiopulmonary resuscitation (CPR) and first aid training prior to administering medication with the following exceptions: FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 7 staff files and identified one staff member, designated IPS Dana H., to be fully delegated in medication administration; however, the delegation has not been completed by the center's current child care health consultant. Reviewed Dana's file and identified it to contain current CPR and First Aid training from an unapproved vendor. Correction: Ensure at least one staff member is on duty who is trained and delegated in medication administration by the center's current child care health consultant. Ensure the staff member also has current CPR and first aid training from an approved vendor. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: ratio. Marked corrected in the state record.

2.233.A.3 · Rooms licensed for specific ages of children cannot be used for other ages of children without the prior written approval of the licensing authority.

The program's plan for having infants and toddlers access the outdoor area requires infants and toddlers to go through the preschool/pre-K classroom. The program has submitted a waiver for this that has not yet been approved. Correction: Rooms licensed for specific ages of children cannot be used for other ages of children without prior written approval of the licensing authority. Correct and respond with a plan for ongoing compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Marked corrected in the state record.

2.221.B.1 · When the parent(s)/guardian(s) applies sunscreen, the center must have a mechanism for documenting application times to ensure sunscreen is reapplied as directed by the product label. If documentation of application time is not available, the center must ensure that sunscreen is applied thirty (30) minutes before going outdoors. If the child will be outside for more than one (1) hour, sunscreen must be reapplied every two (2) hours.

Reviewed the parent handbook and the child enrollment forms and identified both documents to request the parents/guardians to apply sunscreen to children before drop-off at the center. Observed the facility does not yet have a mechanism for documenting application times to ensure sunscreen is reapplied as directed by the product label. Correction: Obtain a mechanism for documenting application times to ensure sunscreen is reapplied as directed by the product label. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Marked corrected in the state record.

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.

On the preschool playground, observed a metal ladder and building materials. On the toddler playground, observed building materials, exposed weed matting, and adult gardening tools. If accessible to children, these items could pose a potential safety hazard. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Ensure outdoor play areas are kept free from hazardous materials. Correct and respond with a statement of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: physical safety. Marked corrected in the state record.

2.217.A.3 · The director of the center must be present at the center at least sixty percent (60%) of any day that the center is open.

The director of the program, Roubhie Fairchild, is currently the director of record of another preschool program. Both programs are open Monday-Friday from 7am to 6pm, making it impossible for the director to be present at both programs for 60% of the day. Correction: Ensure the director of the center is present at the center at least 60% of any day that the center is open. Correct and respond with a plan for ongoing compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.122.B · Prior to the original license being issued, all child care facilities, except for foster homes and specialized group facilities, that are providing care for three or fewer children who are determined to have a developmental disability by a community centered board or who have a serious emotional disturbance, must submit to the Department written approval from the local zoning department approving operation of the facility. The approval must include the address of the child care facility and the ages and number of children to be served. The facility must also submit written zoning department approval to the Department any time there is a change to the license, including moving the facility to another location, increasing the capacity, or adding different ages of children.

Facility has not yet received a zoning letter for the program. Correction: Obtain written approval for operation from the local zoning department. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: ratio. Marked corrected in the state record.

2.210.A.2 · A record must be maintained, either written or electronic, for each staff member that includes the following: Verification of qualifications and training.

Reviewed 7 staff files and identified the program's designated IPS, Dana H., does not have all required documentation necessary to meet IPS qualification. Correction: Obtain verification of hours letters documenting hours worked with infants and toddlers for Dana. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.213.A · All staff must complete a pre-service building and physical premises safety training prior to working with children. The training must include identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, vehicular traffic handling and storage of hazardous materials and the appropriate disposal of biological contaminants.

Reviewed 7 staff files and identified Director Roubhie and ECT Carlos lacking documentation of a building and physical premises safety training specific to the facility. Correction: Obtain documentation of a building and physical premises safety training specific to the facility for Roubhie and Carlos and ensure this is completed for all staff prior to working with children. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: recordkeeping. Marked corrected in the state record.

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.

Reviewed 7 staff files and identified Director Roubhie's file lacking documentation of a current Department-approved standard precautions training. Correction: Obtain current Department-approved standard precautions training for Roubhie and ensure this training is completed for all staff prior to working with children. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.213.C · Staff working with infants less than twelve (12) months old must complete a Department-approved safe sleep training prior to working with infants less than twelve (12) months old. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 7 staff files and identified Director Roubhie's file lacking documentation of a Department-approved safe sleep training. Correction: Obtain current Department-approved safe sleep training for Roubhie and ensure this training is completed for all staff prior to working with infants. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Category: physical safety. Marked corrected in the state record.

2.206.B · The written policies and procedures must be developed, implemented, and followed, and must include at a minimum the following information:

Reviewed the center's parent handbook and identified policies 2.206.B.4,5,11,19,25, and 27 to be missing or insufficient. Correction: Ensure all required policies are developed. Correct and respond with verification of compliance by 3/29/24. Correct by 03/29/2024

Corrected Corrected by Mar 29, 2024

Marked corrected in the state record.

2.209.A.2 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include:Parent(s)/guardian(s) names; home and e-mail addresses; telephone numbers, including home, work, and cell numbers; employer name and work address; and, any special instructions as to how the parent(s)/guardian(s) may be reached during the hours that the child is in care at the center;

Reviewed the child enrollment forms and identified a section allowing parents/guardians to document special instructions for reaching them during child care hours to be missing. Correction: Obtain a mechanism to allow parents/guardians to document any special instructions for reaching them during

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.