7.701.100.F.2 · . 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.

The program did not have record of drills being completed over the last twelve (12) months. Correction: Immediately ensure drills are being conducted for fire, tornado and emergencies and are recorded and maintained over the last twelve (12) months. Provide statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.41.F · . Prior to working with children, the staff member must read and be instructed on the policies and procedures of the center, including those relating to hygiene, sanitation, food preparation practices, proper supervision of children, and reporting of child abuse. Staff members must sign a statement indicating that they have read and understand the center's policies and procedures.

Lauren F., and Sara M. did not have a signed statement indicating they have read and understand the program's policies and procedures. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately ensure that prior to working with children staff sign a statement indicating that they have read and understand the program's policies and procedures. Provide documentation and statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: supervision. Marked corrected in the state record.

7.701.32.D.1.a.1 · . Individuals who have obtained a successfully completed CBI or FBI record check may care for children, for no longer than ninety (90) calendar days, while waiting for all other required background checks to be completed. The individual must be supervised at all times by an individual who has successfully completed all required background checks.

Lauren F., Sydney W., and Sara M. did not have proof of a completed TRAILS 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 Lauren F., Sydney W., and Sara M. reviewed the video within 24 hours. Submit documentation of TRAILS for Lauren F., Sydney W., and Sara M. with written response to Specialist. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: supervision. Marked corrected in the state record.

7.701.33.D.4.a · . Criminal background check requests must be submitted and 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-aged child care facilities, family child care homes, and qualified exempt provider homes.

Lauren F., did not have proof of a CBI clearance letter. Lauren F., and Sydney W., did not have proof of a FBI 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 Lauren F., and Sydney W., reviewed the video within 24

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

7.701.34.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.

The fire inspection on site was expired. Correction: Ensure fire inspections are being completed every two (2) years and documentation of an approving fire inspection is maintained at the facility. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

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

7.701.52.C.2 · . Reports Made to the Department Within Ten (10) Working Days - Change of director of facility or agency;

The site director changed from last year to this year and the program did not submit a change of director letter notifying licensing of the change. Correction: Ensure that within ten (10) days of a director change a report is submitted notifying licensing of the change. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Marked corrected in the state record.

7.701.53.A · . A child care facility must require each staff member of the facility to read and sign a statement clearly defining child abuse and neglect pursuant to state law and outlining the staff member's personal responsibility to report all incidents of child abuse or neglect according to state law.

Lauren F. did not have a child abuse and neglect statement signed and in her file. Correction: Ensure each staff member has read and signed a statement defining child abuse. Provide documentation and

Open Not marked corrected in the state record

Open / not marked corrected.

7.701.56.A · . At all times during the operating hours of the facility, except for foster care homes, the facility/agency must post the current child care license in a prominent and conspicuous location easily observable by those entering the child care facility or agency. For foster care homes, the certificate must be available for review/upon request of the public.

The license for the facility was not posted, instead an email from 11/2022 indicating their license was approved and would be sent to the facility was posted. Correction: Ensure that at all times during operating hours the child care license is posted in a prominent location. Provide statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Marked corrected in the state record.

7.701.56.B · . At all times during the operating hours of a family child care home, child care center, school-age child care center, or children's resident camp, the facility must post its most recent licensing inspection report or a notice as to where the report may be reviewed at the facility by the parent or legal guardian of a child or their designee.

The most recent licensing inspection or notice where reports can be reviewed was posted at the facility. Correction: Ensure that at all times during operating hours the more recent licensing inspection or notice were reports can be reviewed must be posted in a prominent location. Provide statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Marked corrected in the state record.

7.701.56.C · . At all times during the operating hours of a family child care home, child care center, preschool, school age child care, children’s resident camp, and neighborhood youth organization, the facility must post in a prominent and conspicuous location information regarding the procedures for filing a complaint with the Colorado Department of Human Services, Division Of Early Care And Learning, including the telephone number and mailing address. All 24-hour care agencies and facilities providing out-of-home care and day treatment centers must post in prominent and conspicuous FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ location information regarding the procedures for filing a complaint with the Colorado Department of Human Services, division of child welfare, including the telephone number and mailing address. For foster care homes and child placement agencies, information for filing a complaint must be made available upon request.

The complaint reporting procedures for licensing and CPS were not posted at the facility. Correction: Ensure that at all times during operating hours the procedures for filing a complaint with licensing or CPS are posted in a prominent location. Provide statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Marked corrected in the state record.

7.701.56.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.

The staff to child ratio's were not posted in the facility. Correction: Immediately ensure that the licensed capacity and staff to child ratio are posted in the program. Provide statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: ratio. Marked corrected in the state record.

7.701.8 · Perjury Statement- Application forms for Employment with a Child Care Provider. Every application used in the State of Colorado for employment with a child care provider or facility, or for the certification of a foster home, must include the following notice to the applicant: “Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished accordingly.”

Lauren F., and Sara M., did not have a signed perjury statement in their file. Correction: Ensure proof that applicants are provided with a perjury statement. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Marked corrected in the state record.

7.712.32.B · . For security purposes, a daily sign-in/sign-out sheet or other mechanism for parents/guardians must be maintained by the center it must include, for each child in care, the date, the child's name, the time when the child arrived and left the center, and the parent/guardian's signature or other identifier. With a parent/guardian's approval, a child five (5) years of age or older may sign in and out instead of the parent/guardian. Staff must verify attendance periodically throughout the day.

Upon arrival staff were unsure how many children were in their care. A child arrived on their own and were not signed-in by a parent. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately ensure that parent's sign in and out their children in care. Staff must also verify attendance periodically throughout the day. Provide statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Marked corrected in the state record.

7.712.41.D · . Each staff member and regular volunteer as defined in section 7.712.44.C must complete an annual health history. The health history must be maintained in a secure location.

Lauren F. did not have a health history in their file for review. Correction: Ensure each staff member completes an annual health history. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

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

7.701.100.A · . Prior to caring for children, all staff must complete a State Department-approved training in emergency and disaster preparedness. 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 State Department-approved training

Sydney W. did not have proof of a completed FEMA training prior to working with children. Correction: Immediately ensure that all staff completed a department-approved training in emergency and disaster preparedness prior to working with children. Provide documentation and statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.41.J · All staff members must complete a Department-approved standard precautions training prior to FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ working with children. This training must be renewed annually and may count towards ongoing training requirements.

Lauren F., Sydney W., and Sara M., all completed standard precautions training but they were not signed indicating they were trained on the exposure control plan. Correction: Immediately ensure that staff complete a Department-approved standard precautions training prior to working with children. Provide documentation and statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: recordkeeping. Marked corrected in the state record.

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

Lauren F., and Sara M., did not have proof of a completed building and physical premises training. Correction: Immediately ensure prior to working with children staff complete a building and physical premises training. Provide documentation and statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.C.1 · Program aides must be at least sixteen (16) years of age. Program aides must work directly under the supervision of the program director or program leaders and must never be left alone with children.

Sydney W., was listed as an assistant in her file and did not have proof of the requirements to be a program leader and was alone with 31 children when licensing arrived while Lauren F., was inside. Correction: Immediately ensure that program aides work directly under the supervision of a director or program lead and are never left alone with children. Provide statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: supervision. Marked corrected in the state record.

7.712.42.D.2 · . The date and content of each consultation must be recorded and maintained in the center's files.

The date and content of the CCHC consultations was not available to review. Correction: Ensure the date and content of consultations with the child care health consultant are recorded and maintained at the center. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.D.5 · . All Child Care Health Consultants (CCHC) must show evidence they have completed the FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Colorado Department of Public Health and Environment (CDPHE) immunization course annually.

The CCHC immunization course was expired. Correction: Ensure the CCHC annually completes a CDPHE immunization course. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

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

7.712.42.G.1 · . For every thirty (30) or fewer children in attendance, there must be at least one (1) staff member who holds current Department-approved First Aid and CPR certificate for all ages of children. Such individuals must be with the children at all times when the center is in operation. If children are at different locations, there must be a First Aid and CPR qualified staff member at each location.

Lauren F., and Sydney W., did not have proof of a completed CPR and First Aid certification. There were 42 children in care during the inspection. Correction: Immediately ensure for every thirty (30) children in attendance at least one (1) staff member holds current CPR and First Aid. Provide documentation and statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: ratio. Marked corrected in the state record.

7.712.42.A.1 · The program director must have verifiable education or training in work with school-age children in such areas as recreation, education, scouting or 4-H; and the program director must have completed at least one of the following qualifications:

Lauren F. indicated she was the site director for the program but did not have proof of education or verifiable experience working with children. Correction: Immediately ensure the site director has verifiable education and training with school-age children. Provide documentation and statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.43.C · . There must be at least one (1) program leader providing supervision with each group of thirty (30) or fewer children cared for by the center. When four (4) year olds are in attendance, there must be at least one program leader providing supervision with each group of twenty-four (24) or fewer children cared for by the center.

Upon arrival the program had 31 children and 2 staff members, one who indicated they were a site director and one who is an aide, while a 4 year old was in attendance. At 7:55AM there were two staff and 37 children. At 8:11AM there were 41 children and 2 staff members. A third staff member arrived at 8:24AM as the children were leaving breakfast to go to their classrooms. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately ensure that when four (4) year olds are in care there is at least one program leader for every 24 or fewer children. Provide statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: supervision. Marked corrected in the state record.

7.712.43.D · . The maximum group size for children over the age of five (5) is thirty (30) children. When four (4) year olds are in attendance the maximum group size is twenty-four (24). When the center has the capacity to care for multiple groups of children, they must be separated into developmentally and age appropriate activities. Groups are not required to be separated from each other by permanent or portable dividers or walls.

During the course of the inspection there were anywhere from 31 to 42 children all in one group being cared for by two staff members. Correction: Immediately ensure that maximum group size for children when four (4) year olds are present is 24 children. Provide statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: ratio. Marked corrected in the state record.

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

Sydney W., indicated to licensing that they use the buddy system to allow children to escort themselves to the bathroom or to get water by leaving the group with a second child in care, unsupervised by staff. Observed two (2) children enter the building unsupervised to get water. Additionally, during the inspection Lauren F., was on the phone back facing the playground and Sydney W., was talking one on one with a child and her back turned to the larger group, for roughly 3-4 minutes the majority of the children in care were not being supervised by either staff. Correction: Immediately ensure that school-age children are directly supervised at all times. Provide statement of compliance within 24 hours. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

Category: supervision. Marked corrected in the state record.

7.712.52.A.1.b · . At the time of enrollment, the parent(s) /guardian(s) must provide for each child entering the center: Documentation of immunization status or exemption as required by Colorado Department of Public Health and Environment (CDPHE). Colorado law requires proof of immunization be provided prior to or on the first day of admission.

Four (4) out of ten (10) child files were missing or had immunizations not on an approving immunization FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ record. Correction: Immediately ensure that immunizations are obtained prior to the first day and are recorded as required by CDPHE. Provide documentation and statement of compliance by 9/14/2023. Correct by 08/15/2023

Corrected Corrected by Aug 15, 2023

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

7.712.82.A.1 · The center office must maintain a record for each staff member that includes the: Name, address, and birth date of the individual;

The staff file for Lauren F., did not include her address and birth date. The staff file for Sara M., did not include her address. Correction: Ensure the center maintains a record for each staff member to include their address, and date of birth. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.82.A.3 · The center office must maintain a record for each staff member that includes the: Name, address, and phone number of the person(s) to be notified in the event of an emergency;

The staff file for Lauren F., and Sara M., did not include the name, address and phone number for the employees emergency contact. Correction: Ensure the center maintains a record for each staff member to include the name, address and phone number for the employees emergency contact. Provide documentation and statement of compliance by 9/14/2023. Correct by 09/14/2023

Corrected Corrected by Sep 14, 2023

Category: recordkeeping. Marked corrected in the state record.