2.507.J · Prior to working with children, each staff member must read and be trained on the center’s policies and procedures for the administration of medications. Staff members must sign a statement indicating that they have read and have been trained on the center's administration of medications policies and procedures.

None of the employed staff have yet to sign a statement indicating they have been trained on the center's policies for administering medication. Correction: Prior to working with children staff must read and be trained on the center's policies for medication administration. Correct by 01/09/2025

Corrected Corrected by Jan 9, 2025

Category: ratio. Marked corrected in the state record.

2.509.G.3.b · The date and content of each consultation must be recorded and maintained in the center’s files.

The program did not have any documented consultations with the CCHC. Correction: The date and content of consultations completed with the CCHC must be maintained in the center's files. Correct by 01/09/2025

Corrected Corrected by Jan 9, 2025

Category: recordkeeping. Marked corrected in the state record.

2.509.H · At least one (1) staff member with current Department-approved medication administration training and delegation must be on duty at all times.

None of the staff have a current delegation from the CCHC. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: There must be at least one (1) staff member with current Medication Administration and delegation on duty at all times. Correct by 12/10/2024

Corrected Corrected by Dec 10, 2024

Category: ratio. Marked corrected in the state record.

2.510.H · At all times, school-age child care personnel must be directly supervising the children.

Two (2) staff members were in the gym with 18 children, when LS observed two (2) children walked out to get water without staff member's supervising them. Additionally, when staff in the cafeteria would walkie talkie to the staff in the gym when it was time for children to go home staff would let them leave by themselves to leave without ensuring they made it to their destination. Correction: Staff must directly supervise children at all times. Correct by 12/10/2024

Corrected Corrected by Dec 10, 2024

Category: supervision. Marked corrected in the state record.

2.527.D · 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.

A mop bucket, with water, cleaning compounds and a mop were being store next to the girls bathroom. Correction: Combustibles must be stored inaccessible to children. Correct by 12/10/2024

Corrected Corrected by Dec 10, 2024

Marked corrected in the state record.

2.509.B.1.a · Each program leader must be at least eighteen (18) years of age, demonstrate ability to work with children, and must have completed at least one (1) of the following qualifications: Must have at least three (3) months (455 hours) of verified experience in the care and supervision of four (4) or more children over the ages of four (4) who are not related to the individual; or. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Staff members Krista G., and Janae H., were working together in the gym with 18 children. During the staff file review it was determined the group lead Janae H. did not have an hours letter showing her group lead qualifications. The regional director verified over the phone Janae H. has 10 months of verifiable experience but a letter could not be generated until HR was in the office. Correction: Each program leader must have verified experience of 3 months prior to working as a program lead. Correct by 12/10/2024

Corrected Corrected by Dec 10, 2024

Category: supervision. Marked corrected in the state record.

2.508.D.3 · The center must maintain documentation including the child care health consultant’s Department of Regulatory Agencies (DORA) proof of active licensure in good standing, by the Colorado Medical Board or State Board of Nursing as a physician or registered nurse, a brief biography highlighting applicable knowledge, experience and approximate dates worked as a school nurse or Child Care health Consultant commenced.

The CCHC documentation of licensure was expired. Correction: Ensure the center maintains current documentation of the CCHC licensure in good standing. Provide documentation and statement of compliance by 4/6/2024. Correct by 04/06/2024

Corrected Corrected by Apr 6, 2024

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

2.508.D.5 · All Child Care Health Consultants must show evidence they have completed the Colorado Department of Public Health and Environment (CDPHE) immunization course annually.

The CCHC immunization course was expired. Correction: Ensure annually the CCHC completes a CDPHE approved immunization course. Provide documentation and statement of compliance by 4/6/2024. Correct by 04/06/2024

Corrected Corrected by Apr 6, 2024

Category: health medication. 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.

Mary S. last approving TRAILS clearance letter is from 2015. Correction: Immediately ensure every five (5) years staff obtain an updated TRAILS clearance letter. Within 24 hours ensure Mary S. reviews the Navigating Background Checks Powerpoint. Submit TRAILS clearance letter with written response to licensing specialist. Correct by 03/07/2024

Corrected Corrected by Mar 7, 2024

Category: background checks. 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.

Ashawnti L. did not have proof of a completed emergency and disaster preparedness training. Correction: Immediately ensure prior to working with children staff complete a Department-approved emergency and

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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 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.

Program was missing fire drills for February-April of 2023. Additionally, they were missing tornado drills from March - May, & October of 2023. Correction: Immediately ensure fire drills are being completed monthly and tornado drills are being completed monthly March to October. Provide statement of compliance by 4/6/2024. Correct by 03/07/2024

Corrected Corrected by Mar 7, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.J · All staff members must complete a building and physical premises safety training prior to working with children. The training must include:

Ashawnti L. did not have proof of a completed building and physical premises safety training. Correction: Immediately ensure prior to working with children staff complete a building and physical premises training. Provide statement of compliance by 4/6/2024. Correct by 03/07/2024

Corrected Corrected by Mar 7, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.L · All staff members and regular volunteers must complete a Department-approved training about child abuse prevention, including common symptoms and signs of child abuse within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Ashawnti L. had an expired child abuse and neglect training. Correction: Immediately ensure annually staff complete a Department-approved child abuse and neglect training. Provide documentation and statement of compliance by 4/6/2024. Correct by 03/07/2024

Corrected Corrected by Mar 7, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.M · All staff must have at least one (1) hour of child development training within ninety (90) days of 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.

Ashawnti L. did not have proof of a completed child development training. Correction: Ensure within ninety (90) days of hire complete a department-approved child development training. Provide documentation and statement of compliance by 4/6/2024. Correct by 04/06/2024

Corrected Corrected by Apr 6, 2024

Category: recordkeeping. Marked corrected in the state record.

2.525.A.7 · The center must maintain and update annually a record on each child that includesA complete FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ health history including communicable diseases, chronic illnesses or injuries, immunization history, known drug reactions or allergies, medication records, special diet needs, and health care plans as required in rule section 2.512;

Four (4) out of ten (10) child files had expired healthy history forms in their files. Correction: Immediately ensure parents annually update their child's health history record. Provide statement of compliance by 4/6/2024. Correct by 03/07/2024

Corrected Corrected by Mar 7, 2024

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