2.121.D.5 · Every five (5) years, requests for FBI criminal record checks must be renewed by completing the fingerprint process at an approved vendor. An updated clearance letter or verification of the submission of the request must be obtained prior to five (5) years from the date reflected on the current clearance letter.

Reviewed 12 staff files and observed Abigail K to be lacking documentation of a renewed FBI clearance letter obtained prior to 5 years from the date reflected on the current clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of Clearance Letters for staff members listed above with written response to Specialist. Correct by 07/09/2025

Corrected Corrected by Jul 9, 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 (7) children's files and observed (1) of the files lacking a current authorization for emergency medical care signed by a parent/ guardian. Correction: Immediately (7/09/2025) ensure that the program obtains and maintains documentation of current written authorization for emergency medical care for all children in care. Provide a written statement of compliance within the overall response. Correct by 07/09/2025

Corrected Corrected by Jul 9, 2025

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

2.221.C · When supplied for an individual child, the sunscreen must be labeled with the child's first and last name.

(1) sunscreen within CR-7 not labeled with the child's name Correction: The director immediately (7/09/2025) labeled the sunscreen with the child's first and last name, NO RESPONSE REQUIRED. Correct by 07/09/2025

Corrected Corrected by Jul 9, 2025

Marked corrected in the state record.

2.237.K · Kitchens, including all hazardous items, must be inaccessible to children at all times.

Kitchen door open and accessible to children in care. Correction: The director immediately (7/09/2025) closed the kitchen door and the Kitchen is inaccessible to the children in care. NO RESPONSE REQUIRED. Correct by 07/09/2025

Corrected Corrected by Jul 9, 2025

Category: physical safety. 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.

Reviewed 10 staff files and observed Vanessa B be lacking documentation of a renewed TRAILS clearance letter obtained prior to 5 years from the date reflected on the current clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of Clearance Letters for staff members listed above with written response to Specialist. Correct by 08/26/2024

Corrected Corrected by Aug 26, 2024

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

2.121.D.5 · Every five (5) years, requests for FBI criminal record checks must be renewed by completing the fingerprint process at an approved vendor. An updated clearance letter or verification of the submission of the request FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ must be obtained prior to five (5) years from the date reflected on the current clearance letter.

Reviewed 10 staff files and observed Denise V to be lacking documentation of a renewed FBI clearance letter obtained prior to 5 years from the date reflected on the current clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of Clearance Letters for staff members listed above with written response to Specialist. Correct by 08/26/2024

Corrected Corrected by Aug 26, 2024

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

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 10 staff files and observed Alisha W to be lacking documentation of a renewed Department approved training in standard precautions. Correction: Immediately (8/26/2024) ensure that the program obtains and maintains documentation of a current standard precautions training for all staff to include the above listed staff. Provide a written statement of compliance within the overall response. Correct by 08/26/2024

Corrected Corrected by Aug 26, 2024

Category: recordkeeping. Marked corrected in the state record.

2.213.D · Staff working with children less than three (3) years of age must complete a Department-approved prevention of shaken baby/abusive head trauma training prior to working with children less than three (3) years of age. This training must be renewed every two (2) years and will be counted towards ongoing professional development.

Reviewed 10 staff files and observed Alisha W to be lacking a the Department-approved training Prevention of Shaken Baby/ Abusive Head Trauma. Correction: Immediately (8/26/2024) ensure that the program obtains and maintains current documentation of the Shaken Baby Abusive Head trauma training certificates for all staff who work with children less than 3 years of age to include the above listed staff. Provide a written statement of compliance within the overall response. Correct by 08/26/2024

Corrected Corrected by Aug 26, 2024

Category: recordkeeping. 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 3 staff files and observed Alish W to be lacking documentation of the Department-approved training regarding child abuse prevention. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately (8/26/2024) ensure that the program obtains and maintains current documentation of the Mandated reporter (Child Abuse Preventions and reporting) training to include the above listed staff. Provide a written statement of compliance within the overall response. Correct by 08/26/2024

Corrected Corrected by Aug 26, 2024

Category: recordkeeping. Marked corrected in the state record.

7.702.34.B.4 · The center must maintain and update annually and upon changes, a record on each child that includes: A copy of the child’s health statement completed by a health care provider.

Reviewed (6) children files and observed (2) children lacking documentation of a current health statement. Correction: Provide a written statement of compliance within the overall response ensuring all children have a health statement completed by a healthcare provider. Correct by 10/06/2023

Corrected Corrected by Oct 6, 2023

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

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.

Reviewed (6) children's files and observed (2) children lacking documentation of a current authorization for emergency medical care by a parent/guardian. Correction: Immediately (9/06/2023) ensure that the program obtains and maintains documentation of current written authorization for emergency medical care for all children in care. Provide a written statement of compliance within the overall response. Correct by 09/06/2023

Corrected Corrected by Sep 6, 2023

Category: health medication. 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.

Reviewed 13 staff files and observed Madison C, Arlyne S, Louise B, and Samual N to be lacking documentation of CBI clearance letters and observed Madison C, Arlyne S, and Louise B to be lacking documentation of FBI clearance letters. Correction: Immediately (09/06/2023) ensure that all staff have successfully completed documentation of background clearance prior to having unsupervised access to children. Submit FBI and CBI clearance letters for above listed staff along with a written statement of compliance within the overall response. Correct by 09/06/2023

Corrected Corrected by Sep 6, 2023

Category: supervision. Marked corrected in the state record.

7.702.42.D · Staff working with children less than three (3) years of age must complete a Department-approved Prevention of Shaken Baby/Abusive Head Trauma training prior to working with children less than three (3) years of age. This training must be renewed every two (2) years and will be counted towards ongoing professional development.

Reviewed (13) staff files and observed Ann M. lacking a the Department-approved training Prevention of Shaken Baby/ Abusive Head Trauma. Correction: Immediately (9/06/2023) ensure that the program obtains and maintains current documentation of the Shaken Baby Abusive Head trauma training certificates for all staff who work with children less than 3 years of age to include the above listed staff. Provide a written statement of compliance within the overall response. Correct by 09/06/2023

Corrected Corrected by Sep 6, 2023

Category: recordkeeping. Marked corrected in the state record.

7.702.42.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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ must be renewed annually.

Reviewed 13 staff files and observed Deanna D lacking documentation of the Department-approved training regarding child abuse prevention. Correction: Immediately (date) ensure that the program obtains and maintains current documentation of the Mandated reporter (Child Abuse Preventions and reporting) training to include the above listed staff. Provide a written statement of compliance within the overall response. Correct by 09/06/2023

Corrected Corrected by Sep 6, 2023

Category: recordkeeping. Marked corrected in the state record.