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 23 staff files and identified Director Jessica's file (DOH 8/19/2024) to be missing department-approved training about child abuse prevention. Correction: Obtain documentation of department-approved training in child abuse prevention for all staff within 30 days of hire. Correct immediately and respond with verification of compliance by 4/27/2025. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Category: recordkeeping. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ must be held monthly from March to October. A record of all emergency drills held over the past twelve (12) months must 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.

Missing tornado drills from August 2024 Correction: Tornado drills must be held monthly from March to October. Correct immediately and respond with a plan of ongoing compliance by 4/27/2025 Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Category: recordkeeping. Marked corrected in the state record.

2.220.J · If a medication is out of date or left over, the parent(s)/guardian(s) is responsible for picking up the medication. If the parent(s)/guardian(s) do not respond, the center must dispose of the medications as required by the Colorado Department of Public Health and Environment.

Reviewed 11 child medications, observed 2 children with expired medications. Correction: If a medication is out of date or left over, the parent(s)/guardian(s) is responsible for picking up the medication. If the parent(s)/guardian(s) do not respond, the center must dispose of the medications as required by the Colorado Department of Public Health and Environment. Correct immediately and respond with a plan of ongoing compliance by 4/27/2025 Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

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

2.218.C.5 · The individual health care plan must be updated at least every twelve (12) months from the date of the initial plan and as changes occur. The plan must include all information needed to care for the child, must be signed by the health care provider, parent(s)/guardian(s) and must include, but not be limited to, the following:

Reviewed 11 child medications, observed 2 health care plans to be missing a parent signature. Correction: Obtain a parent signature for all health care plans. Correct immediately and respond with a statement of ongoing compliance by 4/27/2025. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Category: health medication. 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 exemption be provided prior to or on the first day of admission.

Reviewed 13 child files and observed ch 6's file to be missing an immunizations card. Correction: Obtain immunizations for all children. Correct immediately and respond with a statement of compliance by 4/27/2025. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

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