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 8 staff files and observed ECT Aaliyah (DOH 1/17/24) , ECT Carmen (DOH 8/1/23) , ECT Olga (DOH 5/10/21) and Assistant Director Elsa (DOH 1.5.15) to be missing documentation of completion of Department-approved Standard Precautions training. Correction: Obtain documentation of Department-approved Stand Precautions training for all staff prior to working with children. Correct immediately and send a copy of training certificates along with written response to specialist. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 8 staff files and observed ECT Carmen, (DOH 8/1/23) and ECT Olga (DOH 5/10/21) to be missing documentation of completion of Department-approved Shaken baby/abusive head trauma training. Correction: Obtain documentation of Department-approved Shaken baby/abusive head trauma training for all staff prior to working with children. Correct immediately and send a copy of training certificates along with written response to specialist. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

Category: recordkeeping. 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 8 staff files and observed ECT Aaliyah file to be missing documentation of completion of Department-approved introduction to First Aid and CPR module. Correction: Obtain documentation of Department-approved introduction to First Aid and CPR module. Correct immediately and send a copy of training certificates along with written response to specialist. Correct by 05/21/2025

Corrected Corrected by May 21, 2025

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 8 staff files and observed ECT Aaliyah, ECT Irma, ECT Carmen and ECT Olgas files to be missing documentation of completion of Department-approved child abuse prevention including symptoms and signs training. Correction: Obtain documentation of Department-approved child abuse prevention including symptoms and signs training. Correct immediately and send a copy of training certificates along with written response to specialist. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

Category: recordkeeping. Marked corrected in the state record.

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 8 staff files and observed ECT Aaliyah's file to be missing current medical statement. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Obtain documentation of health statements for all staff within 30 days of date of hire. Send a copy missing health statements to the licensing specialist with the written response Correct by 05/21/2025

Corrected Corrected by May 21, 2025

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

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.

Identified through the provider's statement that emergency drills have not been completed. Correction: Fire drills must be held monthly, tornado drills must be held monthly between March to October, and other emergency drills must be held quarterly so that all occupants are familiar with the drill procedure and their conduct during a drill is a matter of established routine. Record of drills must include date, time, number of adults, number of children, and the amount of time taken to evacuate. Correct immediately. Ensure that emergency drills are conducted and documented in full. Document compliance to the Licensing Specialist with the written response. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

Category: recordkeeping. Marked corrected in the state record.

2.130.B · During the hours of operation, the facility’s most recent licensing, fire department, and health department inspection reports must be accessible to parents and legal guardians of children in care or their designee and to parents and legal guardians considering placing their children in care at the facility. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Fire Inspection to be expired as of 04/22/24. Correction: The facility must have the most recent fire department inspection for review. Correct immediately and send documentation of current fire inspection with written response to licensing specialist. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

Category: ratio. Marked corrected in the state record.

2.121.D.4 · Requests for a criminal record check, other than those required per this rule section 2.121(D)(4) must be completed at an approved vendor within five (5) working days of the day that the individual begins to work at the facility or agency.

Reviewed 8 staff files and observed Assistant Director Elsa file to be missing CBI and FBI background checks. Correction: Staff who have successfully completed their CBI or FBI background checks may care for children while directly supervised by a staff member who has completed all required background checks for up to 90 days. Correct immediately. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) webpage PowerPoint on the CDEC website. Submit verification that the staff members named above have reviewed the PowerPoint within 24 hours. Send copies of clearance letter(s) to the Licensing Specialist. Document compliance with the written response. Correct by 04/21/2025

Corrected Corrected by Apr 21, 2025

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

2.209.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 5 child files and observed CH1 file to have an expired health statement Correction: Obtain a current health statement for all children enrolled. Send copies of missing health statement to the licensing specialist with the written response. Correct by 05/21/2025

Corrected Corrected by May 21, 2025

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

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 4 child files and observed CH 3 missing documentation of current health statement signed and dated by health care provider. Correction: Obtain a written statement of compliance ensuring all student files have a current health statement signed and dated by a health care provider per the above guidelines. Correct and respond with statement of compliance by 6/6/24. Correct by 06/06/2024

Corrected Corrected by Jun 6, 2024

Category: ratio. Marked corrected in the state record.

2.220.J · If a medication is out of date or left over, the parent(s)/guardian(s) is responsible for picking up the medication. If the parent(s)/guardian(s) do not respond, the center must dispose of the medications as required by the Colorado Department of Public Health and Environment.

Reviewed medications for three children and observed one medication to be expired (expired 3/30/24). FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately ensure that the parent/guardian is responsible for picking up all out of date or left over medication. If the parent/guardians do not respond the center must dispose of the expired medications per CDPHE guidelines. Correct immediately and respond with a written statement of compliance by 6/6/24. Correct by 05/06/2024

Corrected Corrected by May 6, 2024

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

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.

During walk-through observed connecting cubes and small puzzle pieces accessible to children in JC classroom that poses a choke hazard accessible to children under three years of age. Correction: Keep all items small enough to fit in a choke tube inaccessible to children at all times. **Corrected at time of visit- Director moved items out of classroom to be inaccessible to children on 5/6/24.** No response required. Correct by 05/06/2024

Corrected Corrected by May 6, 2024

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