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 5 staff files and observed no current documentation of Trails clearance letter for staff members Melissa. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Melissa has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letter for staff member Melissa with written response to the Specialist. Correct by 01/24/2025

Corrected Corrected by Jan 24, 2025

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

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, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 2 child files and observed 1 child to have expired documentation of emergency medical authorization. Correction: Obtain and maintain current documentation of emergency medical authorization. Correct by 01/24/2025

Corrected Corrected by Jan 24, 2025

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.

Reviewed 5 staff files and observed no current documentation of Introduction to First Aid and CPR training for staff member Kajanee. Correction: Obtain and maintain current documentation of Introduction to First Aid and CPR training for staff member Kajanee. Correct by 02/23/2025

Corrected Corrected by Feb 23, 2025

Category: recordkeeping. Marked corrected in the state record.

2.236.A.1 · If the office space is accessible to children, it must be free of hazards.

Disinfectant deodorant spray and Clorox wipes labeled keep out of reach in the front office accessible to children and posing a potential hazard. Correction: Immediately make all hazardous areas inaccessible to children. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

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

2.229.E · Thumb tacks must not be used in areas accessible to children less than three (3) years of age.

Thumb tacks on a bulletin board in the front office area accessible to children under the age of 3 years. Correction: Immediately make all hazardous areas inaccessible to children. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ the submission of the inquiry form must be obtained before five (5) years from the date reflected on the current clearance letter.

Reviewed 5 staff files and observed no current documentation of Trails clearance letter for staff member Susan. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Susan has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letter for staff member Susan with written response to Specialist. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

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

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 5 staff files and observed no current documentation of Abuse Prevention reporting for staff member Brianna. Correction: Obtain and maintain current documentation of Abuse Prevention training. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

Category: recordkeeping. Marked corrected in the state record.

2.230.B · Indoor and outdoor equipment, materials, and furnishings must be sturdy, safe, and free of hazards.

Three large stuffed animals in the toddler room labeled 'not intended for use by children under 3 years of age' and accessible to children under 3 years of age, broken plastic sifting tray on the playground with sharp edges accessible to children and posing a potential hazard. Correction: Immediately make all hazardous items inaccessible to children. CORRECTED AT TIME OF INSPECTION - director removed stuffed animals from the toddler room and threw away the plastic sifting tray making them inaccessible to children. No response required. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

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

2.209.A · An admission record must be completed for each child prior to or at the time of the child's admission. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ This record must be updated annually and when changes occur. The admission record must include:

Reviewed 4 child files and observed no current documentation of admission record for 3 children. Correction: Obtain and maintain current documentation of admission record for all enrolled children annually. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

Category: recordkeeping. Marked corrected in the state record.

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 4 child files and observed 3 children to have no current documentation of written authorization for emergency medical authorization. Correction: Obtain and maintain current documentation of written authorization for emergency medical authorization for all enrolled children annually. Correct by 03/05/2024

Corrected Corrected by Mar 5, 2024

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