Lionheart Children's Academy at ACC

2.223.C.2 · In the infant room, soft bedding or materials that could pose a suffocation hazard are not permitted in cribs, futons approved for infants, or other approved sleep/rest equipment. Soft bedding means, but is not limited to, any soft sleep surface like bumper pads, pillows, blankets, quilts, comforters, sleep positioning devices, sheepskins, blankets, flat sheets, cloth diaper bibs, plush toys, pacifiers with stuffed animals attached, and stuffed animals.

There was a small stuffed animal blanket in an infant crib used by a 15 month old infant. The infant was not in the crib at the time of inspection. Correction: Corrected at the time of inspection. Staff removed the stuffed animal blanket from the crib and stated the child does not sleep in the crib with the toy. A written response is not required. Correct by 02/06/2025

Corrected by Feb 6, 2025

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2.230.C.2.a · The maximum height for toddler climbing equipment cannot exceed thirty-two (32) inches.

The EPS 1 toddler classroom was using the preschool playground and 2 year olds were climbing on the climbing structure that measures 50 inches high. Correction: Immediately, ensure the maximum height of climbing equipment used by toddlers is 32 inches. The toddler class went inside at time of inspection. Submit a written statement of compliance by 3/5/25. Correct by 02/06/2025

Corrected by Feb 6, 2025

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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 35 staff files. Precious W, Dasha M and Nicole W did not have documentation of a current standard precautions training. Correction: Immediately, obtain a current standard precautions training for Precious W, Dasha M and Nicole W. Submit documentation and a written statement of compliance by 3/5/25. Correct by 02/06/2025

Corrected by Feb 6, 2025

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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 35 staff files. Dasha M and Ava C did not have documentation of health statement from a health care provider. Correction: Obtain a health statement signed by a health care provider for all staff within 30 days of admission and an annual self-reported health history for all staff. Submit a written statement of compliance by 3/5/25. Correct by 03/05/2025

Corrected by Mar 5, 2025

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

Reviewed 20 child files. 2 child files did not have documentation of a current health statement. Correction: Obtain a health statement for each child within 30 days of admission and within 30 days of expiration. Submit a written statement of compliance by 3/5/25. Correct by 03/05/2025

Corrected by Mar 5, 2025

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

There was diaper creams and diaper wipes labeled "keep out of reach of children" accessible in a diaper changing table with a broken lock in the EPS 3, Correction: Immediately, make all items labeled "keep out of reach of children" inaccessible to children at all times. Submit documentation and a written statement of compliance by 1/23/25. Correct by 01/23/2025

Corrected by Jan 23, 2025

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

There was sanitizing spray accessible to children on a shelf in the Trailblazers classroom. Correction: Corrected at the time of inspection. The sanitizing spray was placed on top of the cupboard, inaccessible to children. A written response is not required. Correct by 11/14/2024

Corrected by Nov 14, 2024

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2.229.H · Sharp tools and instruments must be stored in areas inaccessible to children.

There were sharp teacher scissors accessible to children in a drawer in the Trailblazers classroom. Correction: Corrected at the time of inspection. The scissors were placed ontop of a shelf, inaccessible to children. A written response is not required. Correct by 11/14/2024

Corrected by Nov 14, 2024

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2.225.A · Guidance used at the center must be appropriate to the development of the child and is used as an opportunity to teach children social-emotional skills, such as self-regulation, problem-solving, and empathy for others.

It was determined through staff statement that a staff member became upset with a 4 year old child's behavior, carried the child in their chair over to another part of the room, setting the chair and child down. The staff member was speaking to the child in a harsh tone close to the childs face and returned 2-3 times to tell the child to stop crying. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately, ensure guidance used at the center is appropriate to the development of the child and used as an opportunity to teach social emotional skills. Submit a written plan and statement of compliance by 11/21/24. Correct by 11/14/2024

Corrected by Nov 14, 2024

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

A sensory bottle with small bells inside had an unsecured screw top cap posing a choking hazard in the infant classroom. Correction: Corrected at the time of inspection. A written response is not required. Correct by 09/18/2024

Corrected by Sep 18, 2024

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2.217.A.14 · Staff to Child Ratios by ages of children and number of staff- 6 weeks to 18 months (infants):1 staff member to 5 infants; 12 months to 36 months: 1 staff member to 5 toddlers; 24 months to 36 months: 1 staff member to 7 toddlers; 2-1/2 years to 3 years:1 staff member to 8 children; 3 years to 4 years: 1 staff member to 10 children; 4 years to 5 years: 1 staff member to 12 children; 5 years and older: 1 staff member to 15 children; Mixed-age group 2-1/2 yrs to 6 yrs: 1 staff member to 10 children.

Licensing Specialist reviewed name-to-face attendance sheets and determined that the Preschool 1 classroom was out of ratio from 7:37am to 8:08am. The PreK classroom was out of ratio from 8:08am-9:03am. Correction: Immediately, ensure that staff-to-child ratio's are maintained at all times. Submit a written plan and statement of compliance by 8/30/24. Correct by 08/23/2024

Corrected by Aug 23, 2024

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

There were pom-pom's in the sensory table accessible to children in the Early Preschool 2 classroom. Correction: Corrected at the time of inspection. The teacher removed the pom pom's from the classroom. A written response is not required. Correct by 08/23/2024

Corrected by Aug 23, 2024

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

There were small, broken crayons that pose a choking hazard accessible and being used by the children in the EPS 3 classroom. Correction: Immediately, make all choke and inhalation hazards inaccessible to children less than 3 years of age. ***Corrected at the time of inspection. The teacher removed all small, broken crayons from the classroom. A written response is not required. Correct by 02/26/2024

Corrected by Feb 26, 2024

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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 17 child files. 4 children had expired health statements. 1 child did not have a health statement signed by a health care provider and 6 children did not have health statements that included the date of the next visit required by the health care provider. Correction: Review child files and ensure that each child has a current health statement, signed and dated by the health care provider and includes the date of next visit required by health care provider. Submit a written statement of compliance by 3/27/24. Correct by 03/27/2024

Corrected by Mar 27, 2024

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2.121.D · Each owner and employee sixteen (16) years of age or older of a facility or agency shall complete the fingerprint process at an approved vendor. Payment of the fee for the criminal record check is the responsibility of the individual being checked or the facility or agency. The results of the criminal record check, the CBI and/or Federal Bureau of Investigation (FBI) response letters, must be maintained at the home, center, facility, or agency and must be available FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ for review upon request by a Licensing Specialist.

Reviewed 30 staff files. The staff file for Ellen M did not have documentation of the CBI clearance letter. Correction: Immediately, ensure that the CBI and FBI response letters are maintained at the facility and are available for review upon request by a licensing specialist. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Ellen M has reviewed the powerpoint within 24 hours. Submit documentation of CBI clearance letter for Ellen M with a written statement of compliance by 3/27/24. Correct by 02/26/2024

Corrected by Feb 26, 2024

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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 30 staff files. Julia G did not have documentation of a current standard precautions training. Correction: Immediately, ensure all staff complete a Department approved standard precautions training prior to working with children and ensure the training is updated annually. Submit documentation and a written statement of compliance by 3/27/24. Correct by 02/26/2024

Corrected by Feb 26, 2024

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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.

Reviewed 30 staff files. Julia G did not have documentation of First Aid & CPR certification or the Introduction to First Aid and CPR module. Correction: Ensure that all staff not required to by rule to be certified in First Aid and CPR complete a Department approved Introduction to First Aid and CPR module within 30 days of employment. Submit documentation and a written statement of compliance by 3/27/24. Correct by 03/27/2024

Corrected by Mar 27, 2024

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2.213.L · All staff must have at least one (1) hour of child development training within ninety (90) days of FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ employment. This training must include the major domains (cognitive, social, emotional, physical development and approaches to learning). This training is required once and will count toward ongoing training requirements if taken after the date of hire.

Reviewed 30 staff files. Julia G did not have documentation of a 1 hour child development training. Correction: Ensure that all staff complete at least 1 hour of child development training within 90 days of employment. Submit documentation and a written statement of compliance by 3/27/24. Correct by 03/27/2024

Corrected by Mar 27, 2024

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2.212.J.1.a · 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:State criminal history check

Reviewed 30 staff files. Mary M did not have documentation of the State-based clearance letter and was working alone with children in room 154. Correction: Immediately, ensure all staff must have submitted and successfully completed the State-based background check prior to working alone with children. The Director immediately placed a fully background checked staff member in the classroom with Mary M. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Mary M has reviewed the powerpoint within 24 hours. Submit documentation of State-based background clearance letter for Mary M with written statement of compliance by 3/27/24. Correct by 02/26/2024

Corrected by Feb 26, 2024

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

Small pom poms on an art display accessible to children under 3 years of age in the Early Preschool 1 classroom posing a potential choking hazard. Correction: Immediately make all items that pose a potential choking hazard inaccessible to children under 3 years of age. ***Corrected at the time of inspection. Assistant Director removed the items from the room. Correct by 01/12/2024

Corrected by Jan 12, 2024

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2.218.C.5.c · 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: Medical equipment or adaptive devices, including instructions;

A child in the infant classroom with adaptive medical equipment without documentation of a health care plan. Correction: Immediately obtain documentation of a completed health care plan. Correct by 12/21/2023

Corrected by Dec 21, 2023

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

Plastic google eyes posing a potential choking hazard in the Early Preschool 2 classroom where children present are under 3 years of age. Correction: Immediately remove all items that pose a potential choking hazard to children under 3 years of age. ***Corrected at the time of inspection. Staff removed the google eyes. Correct by 12/21/2023

Corrected by Dec 21, 2023

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7.702.45.B.1.c · Prior to being assigned a group of children, the Infant Program Early Childhood Teacher must complete eight (8) hours of orientation in the infant program under the supervision of the Infant Program Supervisor. The orientation may include, but not limited to, the following topics:

Megan C. was working in the Infant One Room (rm. 123) without proof of an eight (8) hour infant room orientation. This is a violation of stipulation O of the probationary license. Correction: Immediately ensure that prior to working with infants, teachers complete an eight (8) hour orientation under the supervision of the Infant Program Supervisor. Provide documentation and statement of compliance with written response. Correct by 11/03/2023

Corrected by Nov 3, 2023

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7.702.51.A.2.b · At the time of admission, the parent(s)/guardian(s) must provide for each child entering the center: 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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.

Two (2) out of fourteen (14) child files reviewed did not have a signed health statement within thirty (30) days of admission. This is a violation of stipulation T of the probationary license. Correction: Obtain current health statements for children within 30 days of enrollment and maintain current health statements for children on file. Correct by 11/17/2023

Corrected by Nov 17, 2023

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7.702.51.A.2.a · 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. Colorado law requires proof of immunization status or exemption be provided prior to or on the first day of admission.

Two (2) out of fourteen (14) child files reviewed did not have an immunization record on file. Correction: Immediately obtain documentation of child immunization records on CDPHE approved forms. Correct by 11/03/2023

Corrected by Nov 3, 2023

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7.702.34.A.7 · 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.

One (1) out of fourteen (14) child files had an expired authorization for emergency medical care. Correction: Immediately obtain documentation of current emergency medical authorizations for children. Correct by 11/03/2023

Corrected by Nov 3, 2023

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

Mr. Bubble foaming bath soap labeled “keep out of reach of children”, was accessible to children next to the hand washing sink in Room 117 - Early PRS 1. This is a violation of stipulation M of the probationary license. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately make all items labeled “keep out of reach of children” inaccessible to children at all times. ***Corrected at the time of visit by the director, Amber P. removing the soap from the classroom. No response required. Correct by 11/03/2023

Corrected by Nov 3, 2023

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7.702.91.E · Combustibles such as cleaning rags, mops, and cleaning compounds must be stored in well-ventilated areas, separated from flammable materials, and stored in areas inaccessible to children.

Toilet bowl wands were stored on the floor in bathrooms used by children in Room 112 and 117. Correction: Immediately store all cleaning supplies inaccessible to children at all times. ***Corrected at the time of visit by the director, Amber P. removing the toilet bowl wands from the bathrooms. No response is required. Correct by 11/03/2023

Corrected by Nov 3, 2023

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7.701.33.J.1.a.b.c · 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-aged child care facilities, family child care homes, and qualified exempt provider homes: a. State criminal history check b. State sex offender registry check c. State abuse and neglect registry check

Precious W. was working alone in Preschool Room 1 and had not yet obtained her out of state clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage video on the OEC website. Submit verification that Precious W. reviewed the video within 24 hours. Submit documentation of the Out of State Clearance Letter for Precious W. with written response to Specialist. Correct by 08/28/2023

Corrected by Aug 28, 2023

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

Haleigh K. had an expired health statement. Correction: Ensure that staff annually complete a self-report health history. Provide documentation and statement of compliance by 9/11/2023. Correct by 09/11/2023

Corrected by Sep 11, 2023

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7.702.46.A.14 · Staff to Child Ratios by AGES OF CHILDREN and NUMBER OF STAFF 6 weeks to 18 months (infants): 1 staff member to 5 infants 12 months to 36 months: 1 staff member to 5 toddlers 24 months to 36 months: 1 staff member to 7 toddlers 2-1/2 years to 3 years: 1 staff member to 8 children 3 years to 4 years: 1 staff member to 10 children 4 years to 5 years: 1 staff member to 12 children 5 years and older: 1 staff member to 15 children Mixed-age group 2-1/2 yrs to 6 yrs: 1 staff member to 10 children

Haleigh K. was working the the Early Preschool 2 room with eight (8) children alone. That room is licensed for 2 - 3 year olds with a ratio of 1:7. The classroom additionally had one (1) child who is 1.8 years old in attendance. Correction: Immediately ensure the ratio for children ages 24 months to 36 months maintains a ratio of 1 teacher to 7 children. If children are younger than 24 months the ratio then is 1 teacher to 5 children. Provide statement of compliance within 24 hours. Correct by 08/28/2023

Corrected by Aug 28, 2023

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7.702.81.A.3 · Rooms licensed for specific ages of children cannot be used for other ages of children without FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ the prior written approval of the licensing authority.

A 1.8 year old was observed in the Early Preschool 2 Room, which is licensed for children 2-3 years of age. A 1.11 year old child was observed in the Early Preschool 1 room which is licensed for 2-3 year olds. A 2.11 year old was observed in the Preschool 1 room, which is licensed for 3-4 year olds. Correction: Immediately ensure that children are being cared for in the rooms licensed for that specific age group. Provide statement of compliance within 24 hours. Correct by 08/28/2023

Corrected by Aug 28, 2023

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7.702.51.A.2.b · At the time of admission, the parent(s)/guardian(s) must provide for each child entering the center: 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.

One (1) out of ten (10) child files did not have proof of a health statement and has been enrolled since 2022. Correction: Ensure that within thirty (30) days of enrollment parents submit a health statement to the center for their child. Provide documentation and statement of compliance by 9/11/2023. Correct by 09/11/2023

Corrected by Sep 11, 2023

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