South West Ymca

2.120.J · The results of the abuse and neglect inquiry must be maintained at the center, facility, or agency and must be available for review upon request by a Licensing Specialist.

Reviewed 1 staff file and observed that 1 staff member was missing documentation of the completed abuse and neglect inquiry background check results. Correction: Immediately, 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 TRAILS for staff members with written response to the Specialist. Correct by 12/15/2025

Corrected by Dec 15, 2025

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2.121.D · Each owner and employee sixteen (16) years of age or older of a facility or agency shall complete the fingerprint process at an approved vendor. Payment of the fee for the criminal record check is the responsibility of the individual being checked or the facility or agency. The results of the criminal record check, the CBI and/or Federal Bureau of Investigation (FBI) response letters, must be maintained at the home, center, facility, or agency and must be available FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ for review upon request by a Licensing Specialist.

Reveiwed 1 staff file and observed that 1 staff member was missing documentation of the completed FBI and CBI background check results. Correction: Immediately, 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 FBI and CBI for staff members with written response to the Specialist. Correct by 12/15/2025

Corrected by Dec 15, 2025

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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 1 staff file and observed that 1 staff member was missing documentation of a current abuse prevention training. Correction: Immediately, all employees and regular volunteers must complete the abuse prevention training within 30 days of employment and must be renewed annually. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 12/15/2025

Corrected by Dec 15, 2025

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2.213.H · Within ninety (90) calendar days of employment, all staff required to register with the Colorado Shines Professional Development Information System (listed in rule section 2.208(D)) must complete the Department-approved training course: Introduction to the Early Intervention and Preschool Special Education Programs. This course is required once and will be counted towards ongoing professional development.

Reviewed 1 staff file and observed that 1 staff member was missing documentation of an Introduction to the Early Intervention and Preschool Education Programs. Correction: Within 30 days, all staff required to register with PDIS must complete the Introduction to the Early Intervention and Preschool Education Programs within 90 days of employment. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 01/14/2026

Corrected by Jan 14, 2026

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

On the playground, observed the metal bar that is part of the climbing structure located at the top was broken exposing sharp edges posing a safety hazard. Correction: Immediately, indoor and outdoor equipment, materials, and furnishings must be sturdy, safe, and free of hazards. Submit a written statement of compliance to the Licensing Specialist. Correct by 12/15/2025

Corrected by Dec 15, 2025

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2.230.C.1.a · All climbing equipment eighteen (18) inches or higher must have resilient surfacing of at least six (6) inches in the use zone surrounding the equipment.

On the playground, observed the wood chip resilient materials measured as low as 2 inches throughout the playground and under the climbing structure. Correction: Immediately, climbing equipment 18 inches or higher must have resilient surfacing of at least 6 inches in the use zone surrounding the equipment. Submit a written statement of compliance to the Licensing Specialist. Correct by 12/15/2025

Corrected by Dec 15, 2025

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2.217.A.9 · At least one (1) staff member with the current Department-approved medication administration training and delegation must be on duty at all times.

Cori has completed the 4 hour department approved medication administration training, however the certificate is not valid because part 2 has not been completed by indicating the staff member has been trained on the 1 hour face to face portion of the training. Correction: Immediately 2/15/2024 ensure there is a staff member on duty at all times with current medication administration training. Submit a written statement of compliance by 3/14/2024. Correct by 02/15/2024

Corrected by Feb 15, 2024

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2.205.D · Any center having a director assigned to a classroom must have qualified and adequate staff, allowing the director or qualified staff the ability to attend to the duties of a director as they arise.

Cori is the only staff member present in the licensed program from 7:00 am to 6 pm daily. At the time of inspection, there was no other staff present to allow Cori to attend to the duties of a director. Correction: Immediately by 2/15/2024 ensure there are adequate staff to allow Cori to attend to other duties as they arise. Submit a written statement of compliance by 3/14/2024. Correct by 02/15/2024

Corrected by Feb 15, 2024

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2.217.C.4 · The date and content of each consultation must be recorded and maintained in the center's files for three (3) years.

There is no record of a monthly nurse consultation maintained at the center for the months of June and July 2023. Correction: Maintain a record of monthly nurse consultations for all visits at the center. Submit a written statement of compliance by 3/14/2024. Correct by 03/14/2024

Corrected by Mar 14, 2024

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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.

Three children's files lacking a health statement within 30 days of admission to the program. Correction: Obtain a physical exam to be maintained in each child's file. Submit a statement of compliance by 3/14/2024. Correct by 03/14/2024

Corrected by Mar 14, 2024

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