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 18 staff files and observed SM13's file (DOH 5/8/25) to be missing a current health statement signed by a physician or other health care provider. Correction: Obtain documentation of a current health statement signed by a physician or other health care provider for SM13. Correct within 30 days and respond with verification of compliance by 2/20/26. Correct by 02/20/2026

Corrected Corrected by Feb 20, 2026

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

Reviewed 18 staff files and observed SM5's file to be missing both a current CPR/First Aid certification and module. Correction: Obtain documentation of current CPR/First Aid certification or module for SM5. Correct within 30 days and respond with verification of compliance by 2/20/26 Correct by 02/20/2026

Corrected Corrected by Feb 20, 2026

Marked corrected in the state record.

2.223.C.2.a · Mattresses for cribs and futons must have a properly fitted, clean sheet.

In the Nido classroom, observed 5 cots or mattresses with sheets that were not properly fitted. No children were observed to be in the cribs or on the mattresses at the time of the walk through. Correction: Mattresses for cribs and futons must have properly fitted, clean sheets. Corrected at time of visit- Staff adjusted sheets so that they were properly fitting on 1/20/26. No response required. Correct by 01/20/2026

Corrected Corrected by Jan 20, 2026

Marked corrected in the state record.

2.220.D · Over-the-counter medication must be kept in the originally labeled container and be labeled with the child's first and last name.

Reviewed 4 over-the-counter medications and observed 2 to be missing the child's first and last name. Correction: Over-the-counter medications must be kept in the originally labeled container and be labeled with the child's first and last name. Corrected at time of visit-Staff updated medication containers to include the children's first and last name on 1/20/26. No response required. Correct by 01/20/2026

Corrected Corrected by Jan 20, 2026

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

2.230.C.1.c · Loose fill resilient surface must be raked regularly to retain its resiliency and to retain a depth of at least six (6) inches.

On the primary playground, observed less than 6 inches of resilient surfacing underneath the slide. Correction: Loose fill resilient surface must be raked regularly to retain its resiliency and to retain a depth of at least 6 inches. Corrected at time of visit, staff raked wood chips so that their was 6 inches of depth on 1/20/26. No response required. Correct by 01/20/2026

Corrected Corrected by Jan 20, 2026

Category: physical safety. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 primary playground, observed exposed weed matting, posing a potential tripping hazard. Correction: Outdoor play areas used for children's activities must be checked daily and kept safe and free from hazardous materials. Correct immediately and respond with verification of compliance by 2/20/26. Correct by 01/20/2026

Corrected Corrected by Jan 20, 2026

Category: physical safety. 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 the toddler playground, observed a broken toy crate to be holding children's playground toys. Correction: Indoor and outdoor equipment and furnishings including toy crates must be sturdy, safe, and free of hazards. Correct immediately and respond with verification of compliance by 2/20/26 Correct by 01/20/2026

Corrected Corrected by Jan 20, 2026

Category: physical safety. 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 primary playground, observed exposed weed matting in the shaded corner digging area. This weed matting poses a potential tripping hazard. Correction: All outdoor play areas used for children's activities must be kept safe and free of hazards. Correct immediately and respond with verification of compliance by 3/26/2025. Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

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

2.138.A · Emergency drills, lockdown and active shooter on premises drills must be held at least quarterly but often enough so that all occupants are familiar with the drill procedure and their conduct during a drill is a matter of established routine. Fire drills must be held monthly and be consistent with local fire department procedures. Tornado drills must be held monthly from March to October. A record of all emergency drills held over the past twelve (12) months must FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ be maintained by the facility or center, including date and time of drill, number of adults and children participating, and the amount of time taken to evacuate.

Reviewed facility drill log, observed missing tornado drills for March, April, and May 2024. Observed missing fire drills for June 2024. Observed missing quarterly drills between 3/5/24 and 7/5/24 and between 7/7/24 and 12/24/24. Correction: Emergency drills, lockdown and active shooter on premises drills must be held quarterly. Fire drills must be held monthly and be consistent with local fire department procedures. Tornado drills must be held monthly from march to October. Correct immediately and respond with a plan for ongoing compliance by 3/26/2025. Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

Category: recordkeeping. Marked corrected in the state record.

2.218.B.3 · Admission procedures must be completed prior to the child's attendance at the center and must include: If applicable, a Department-approved health care plan authorized by the child’s health care provider and parent(s)/guardian(s) defining the interventions needed to care for a child who has an identified health or developmental condition or concern including, but not limited to seizures, asthma, diabetes, severe allergies, heart or respiratory conditions, and physical disabilities. Any applicable medications, supplies, and/or medical equipment must be available to the staff prior to the child’s first day of care. The staff working with a child with a health care plan must be informed, trained, and delegated responsibility for carrying out the health care plan by the Department-approved child care health consultant; supervision of the plan and interventions must be documented.

Reviewed 3 health care plans and observed the prescribed medication for ch8 and ch9 to be missing. Correction: Obtain all prescribed medication for all children requiring a health care plan. Correct immediately and respond with a statement of ongoing compliance by 3/26/2025. Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

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 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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 16 staff files and observed staff members Salma and Jenay to be missing current health statements. Correction: 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. Correct within 30 days and respond with verification of compliance by 3/26/2025. Correct by 03/26/2025

Corrected Corrected by Mar 26, 2025

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

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 must be obtained prior to five (5) years from the date reflected on the current clearance letter.

Reviewed 16 staff files and observed staff member Audrey's (DOH 8/12/2019 ) file to have an expired FBI Clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Audrey has reviewed the powerpoint within 24 hours. Submit documentation of FBI Clearance Letters for staff member Audrey with written response to the Specialist by 3/26/2025 Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

Category: background checks. Marked corrected in the state record.

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.

Reviewed 16 staff files and observed staff member Audrey's (DOH 8/12/2019 ) file to have an expired Trails Clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Audrey has reviewed the powerpoint within 24 hours. Submit documentation of Trails Clearance Letters for staff member Audrey with written response to the Specialist by 3/26/2025 Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

Category: background checks. Marked corrected in the state record.

2.216.B.2.a · In the infant program, there must be a qualified infant program supervisor present sixty percent (60%) of the hours of operation of the infant program who is responsible for the care of the infants. An individual qualified as an infant early childhood teacher must be responsible during the remaining time.

After completing a staff file review, identified that the facility did not have a qualified infant program supervisor in the room for 60% of the day. Correction: In an infant program, there must be a qualified infant program supervisor present 60% of the hours of operation of the infant program. Corrected at time of visit-facility moved qualified Infant Program Supervisor into the classroom for the remaining hours of operation 2/26/2025. Respond with a plan of ongoing compliance by 3/26/2025. Correct by 02/26/2025

Corrected Corrected by Feb 26, 2025

Category: supervision. 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 11 staff files, observed Aide Abiline's file to be missing department-approved emergency and disaster preparedness training. Correction: All staff must have department-approved training in emergency and disaster preparedness. Correct immediately and respond with verification of ongoing compliance by 5/4/2024 Correct by 04/04/2024

Corrected Corrected by Apr 4, 2024

Category: recordkeeping. Marked corrected in the state record.

2.120.J · The results of the abuse and neglect inquiry must be maintained at the center, facility, or agency and must be available for review upon request by a Licensing Specialist.

Reviewed 11 staff files and observed Assistant Director Angelina's file to be missing Trails clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that Angelina has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letters for Angelina with written response to Specialist. Correct by 04/04/2024

Corrected Corrected by Apr 4, 2024

Category: background checks. 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 11 staff files, observed ECT Susan and ECT Allison's files to be missing Out of state background check clearance letters. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that Susan and Allsion have reviewed the powerpoint within 24 hours.

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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 6 child files, observed ch3's file to be missing emergency medical authorization. Correction: All child files must have emergency medical authorization. Correct immediately and respond with a plan for ongoing compliance by 5/4/24 Correct by 04/04/2024

Corrected Corrected by Apr 4, 2024

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

2.219.B.4 · Health statements for children over two (2) years of age to seven (7) years of age must be updated in accordance with the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care schedule for routine well child exams.

Reviewed 6 child files, observed ch4 and ch5's files to be missing a health statement. Correction: All child files must have a current health statement. Correct within 30 days and respond with a statement of

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

In the bathroom area of classroom Primary 2, observed a wet-jet mop with bona hard surface cleaner in the mop. This item was accessible to children and labeled "keep out of reach of children" Correction: All items labeled "keep out of reach of children" must be inaccessible. Corrected at time of visit- staff made items inaccessible 4/4/24. Correct by 04/04/2024

Corrected Corrected by Apr 4, 2024

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.

Observed the following hazards to be accessible to children: -In Primary 4, observed a string of decorative holiday lights on the wall to be loose and longer than 18" -In Toddler 2, observed a long, loose cord to an air purifier to be longer that 18" These cords pose a potential strangulation hazard. Correction: All hazardous items must be inaccessible to children at all times. Corrected at the time of visit-staff made items inaccessible to children 4/4/24 Correct by 04/04/2024

Corrected Corrected by Apr 4, 2024

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