2.122.A · Prior to the original license being issued, following the renovation of the facility that would affect the licensing of the facility and at least every two (2) years thereafter, all child care facilities except family child care homes and Neighborhood Youth Organizations must be inspected and obtain an approving inspection report from the local department of health or the Colorado Department of Public Health and Environment and from the local fire department. These reports must be maintained at the facility and be available for review upon request by a Licensing Specialist.

Missing approving health inspection completed on 7/7/17 Correction: Obtain current approving health inspection. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: health medication. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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.

Observed 18 staff files and observed ECT Mary (DOH 1/3/22), ECT Meghan H (DOH 8/22/22), ECT Josh (DOH 7/17/23) to be missing documentation of department-approved introduction to the early intervention and preschool special education programs. Correction: Obtain documentation of department-approved introduction to the early intervention and preschool special education programs for all staff within 90 calendar days of employment. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: recordkeeping. Marked corrected in the state record.

2.127.D · All facilities, except family child care homes must post in every room of the child care facility, excluding bedrooms and living areas, the license capacity of the room and the staff-to-child ratio required by regulation to be maintained for the age of children cared for in the room.

In multipurpose room (The Brook), observed that there was no posting for capacity or staff-to-child ratio. Correction: Capacity and staff-to-child ratio must be posted in all rooms. Correct immediately and respond with verification of compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: ratio. Marked corrected in the state record.

2.133.A · Prior to caring for children, all staff must complete a Department-approved training in emergency and disaster preparedness: Evacuation, Shelter in Place, Lockdown, and Active Shooter on Premises Plans for Children in Care. For seasonal children’s resident camp programs, operating no more than 90 days per calendar year, at least one on site director must be trained in the Department approved training.

Reviewed 18 staff files and observed aides Emily (DOH 8/21/23), Itzel(DOH 7/18/22), Kristie(DOH 5/16/23), and Janae(DOH 5/22/23) to all be missing documentation of completion of department approved emergency and disaster preparedness training prior to working with children. Correction: Obtain documentation of completion of department approved emergency and disaster preparedness training prior to working with children. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: recordkeeping. Marked corrected in the state record.

2.138.B · Drills must be held at unexpected times and under varying conditions to simulate the conditions of an actual fire or other emergency event.

Reviewed drill long and observed the following drills to be missing: FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ -Fire drills: Missing May, July, and August of 2023 -Tornado drills: Missing April-October of 2023 -Other drills: only done in March of 2023 Correction: Fire drills must be conducted monthly, Tornado drills must be conducted monthly for March to October, and "other" type dirlls must conducted quarterly in order to complete all drill types within one year. Correct immdeiately and respond with a plan for ongoing compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: physical safety. 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 9 child files and observed ch 2,4,8,and 9 files to be missing documentation of signed policies and procedures. Correction: Obtain documentation of signed policies and procedures. Correct immediately and respond with verification of compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ electrical hazards, bodies of water, vehicular traffic handling and storage of hazardous materials and the appropriate disposal of biological contaminants.

Reviewed 18 staff files and observed Assistant Director Lindsay (DOH 11/11/21), ECT Claire (DOH 5/16/22) aide Itzel (DOH 7/18/22), Ect Natalia (7/5/22), ECT Alicia (DOH 2/20/23), ECT Josh (DOH 7/17/23) to be missing documentation of pre-service building and physical premises saftey training prior to working with children. Correction: Obtain documentation of pre-service building and physical premises saftey training prior to working with children. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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 18 staff files and observed aide Itzel (DOH 7/18/22), ECT Meghan (DOH 8/22/22), ECT Natalia( DOH 7/5/22), Aide Kristie( DOH 5/16/23), ECT Alicia (DOH 2/20/23) files to be missing documentation of completion of department-approved standard precautions training. Correction: Obtain documentation of completion of department-approved standard precautions training fpr all staff prior to working with children. Correct immediately and respond with verification of compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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 18 staff files and observed Director Devan to be missing documentation of department-approved safe sleep training. Correction: Obtain documentation of completed department-approved safe sleep training for all staff working with infants less than 12 months old. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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

2.213.F · Within thirty (30) calendar days of employment, all employees caring for children, not required by rule FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ to be certified in First Aid and CPR, must complete the Department-approved Introduction to First Aid and CPR module. The module must be renewed every two (2) years.

Reviewed 18 staff files and observed aide Lizzy (DOH 5/17/23), aide Kristie( DOH 5/16/23), and aide Janae( DOH 5/22/23) to be missing documentation of First aid/CPR module and certification. Correction: Obtain documentation of completion of department-approved introduction to first aid and cpr module or certification for all staff within 30 days of hire. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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 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 18 staff files and observed INS Sabrina (DOH 4/17/23), ECT Kathryn (DOH 5/30/23), ECT Mary (DOH 1/3/22), ECT Josh (DOH 7/17/23) files to be missing documentation of department- approved training about child abuse prevention. Correction: Obtain documentation of completion of department- approved training about child abuse prevention for all staff. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: recordkeeping. 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:

Reviewed 18 staff files and observed aides Itzel (DOH 7/18/22) and Lizzie (DOH 7/17/23) to be missing out of state background checks and checklist. Identified through Assistant Director Lindsay statement that both have lift out of state within the last 5 years of date of hire. 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 Aides Itzel and Lizzy have

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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 18 staff files and observed ECT Mary (DOH1/3/22), ECT Meghan H (DOH8/22/22), ECT Alicia (DOH 2/20/23) files to be missing completed department-approved Recognizing the Impact of Bias on Early Childhood Professionals training or other department-approved training on implicit bias. Correction: Obtain documentation of completed department-approved Recognizing the Impact of Bias on Early Childhood Professionals training or other department-approved training on implicit bias for all staff within 90 calendar days of hire for all staff. Correct immediately and respond with verification of ongoing compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: recordkeeping. Marked corrected in the state record.

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ exemption be provided prior to or on the first day of admission.

Reviewed 9 child files and observed ch 3,5,and 9 files to be missing up-to-date school-required immunizations. Correction: Obtain documentation of up-to-date school-required immunizations for all children at the time of admission. Correct immediately and respond with verification of compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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

2.219.B.2 · Within thirty (30) calendar days of admission, and within thirty (30) calendar days following the expiration date of a previous health statement, the parent(s)/guardian(s) of each child must submit a statement of the child’s current health status or written verification of a scheduled appointment with a health care provider. The statement of the child’s current health status must be signed and dated by a health care provider who has seen the child within the last twelve (12) months, or within the last six (6) months for children less than two and one-half (2½) years of age. The statement must include when the next visit is required by the health care provider. All health statements must be kept at the center.

Reviewed 9 child files and observed ch 4 and ch 9 files to be missing documentation of current health statement. Correction: Obtain documentation of all children's current health statement within 30 days of admission. Correct immediately and respond with verification of compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: ratio. 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 9 child files and observed ch 1,2,3,4,5,8, and 9 files to be missing authorization for the administration of topical preperations. Correction: Obtain documentation of authorization for the administration of topical preperations for all children. Correct immediately and respond with verification of compliance by 1/21/24. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: ratio. Marked corrected in the state record.

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

On older child playground, observed a gap large enough to trap a child's fingers (approx. half and inch wide) at the top of the of the smaller "climbing slide" posing a potentail safety hazard. Correction: Maintain all indoor and outdoor equipment to be free from hazards. Correct immediately and respond with a plan for ongoing compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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

2.237.D · Volatile substances such as gasoline, kerosene, fuel oil, oil-based paints, firearms, explosives, and other hazardous items must not be stored in any area of the building used for childcare.

In classrooms Infants,EPS, and Pre K 1, observed charging cords hanging from a wall outlet above shelving unit. Cords were longer than 18" posing a potential saftey hazard. Correction: Keep all hazardous items inaccessible to children at all times. Corrected at time of visit- staff made hazardous items inaccessible to children 12/21/23. No response required. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

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

2.120.C.1.a · 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: For all individuals whose activities involve the care or supervision of children or who have unsupervised access to children, requests must be submitted and successfully completed prior to caring for children or allowing unsupervised access to children.

Reviewed 18 staff files, observed aide Kristie (DOH 5/16/23) file to be missing TRAILS clearance letter and was observed to be working with children. 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) aide Kristie has reviewed the powerpoint within 24 hours. Correct immediately and submit documentation of TRAILS background clearance letter for named staff with written response to Specialist by 1/21/24.. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: supervision. Marked corrected in the state record.

2.121.D.4.a · Criminal background check requests must be successfully completed 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.

Reviewed 18 staff files, observed aide Lizzie (DOH 5/17/23), aide Kristie (DOH 5/16/23) files to be missing FBI clearance letters and Kristie's file to also be missing CBI clearance letter. Both staff were observed to be working directly with children at the time of inspection. 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) aide Kristie and aide Lizzie has reviewed the powerpoint within 24 hours. Correct immediately and submit documentation of FBI and/or CBI background clearance letter for named staff with written response to Specialist by 1/21/24.. Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: supervision. Marked corrected in the state record.

2.216.A.1 · An early childhood teacher, assigned responsibility for a single group of children and working under the supervision of a director, must be at least eighteen (18) years of age and meet at least one (1) of the following qualifications:

During walkthrough ECT Josh (DOH 7/17/23) was observed to be working alone with children in the Pre K 2 classroom with 9 children aged 4 to 5 years. Reviewed 18 staff files and observed Josh's files to be missing verification of ECT qualifications. Correction: Obtain verification of qualifications of all staff for the role that they are assigned as required. Correct immediately and respond with verification of ongoing compliance by 1/21/24 Correct by 12/21/2023

Corrected Corrected by Dec 21, 2023

Category: supervision. Marked corrected in the state record.

2.212.G · All staff members must submit to the center a medical statement, signed and dated by a physician or FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 18 staff files and observed Director Devan (DOH 5/27/23), INS Sabrina (DOH 4/17/23) ,ECT Chelsie (DOH 12/4/23) ECT Kathryn( DOH 5/30/23), ECT Josh (DOH 7/17/23) files to be missing current health statement and annual self reporting form. Correction: Obtain current health statement or annual self reporting form for all staff as required. Correct and respond with verification of ongoing compliance by 1/21/24 Correct by 01/21/2024

Corrected Corrected by Jan 21, 2024

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