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.

One (1) out of seven (7) staff files reviewed had an TRAILS clearance letter, but it was not dated within the last five (5) years. This is a direct violation of stipulation N of the probationary license: Licensee shall timely submit fingerprint-based background checks, Trails abuse/neglect background inquiry request, and complete out-of-state background check process for any new hire. Documentation of the background checks must be maintained in the staff file at all times. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that SM2 has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letter for SM2 with written response to Specialist. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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 must be obtained prior to five (5) years from the date reflected on the current clearance letter.

One (1) out of seven (7) staff files reviewed had an FBI clearance letter, but it was not dated within the last FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ five (5) years. This is a direct violation of stipulation N of the probationary license: Licensee shall timely submit fingerprint-based background checks, Trails abuse/neglect background inquiry request, and complete out-of-state background check process for any new hire. Documentation of the background checks must be maintained in the staff file at all times. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that SM4 has reviewed the powerpoint within 24 hours. Submit documentation of FBI Clearance Letter for SM4 with written response to Specialist. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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

2.218.C.5 · The individual health care plan must be updated at least every twelve (12) months from the date of the initial plan and as changes occur. The plan must include all information needed to care for the child, must be signed by the health care provider, parent(s)/guardian(s) and must include, but not be limited to, the following:

An emergency health care plan reviewed in room 112 did not have a parent signature. Correction: Health care plans must be updated every twelve (12) months and be signed by the health care provider & parents/guardians. Correct immediately on 5/18/2026. Provide statement of compliance by 5/25/2026. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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

2.220.C · Medications must be kept in the original labeled bottle or container. Prescription medications must contain the original pharmacy label.

One (1) emergency medication reviewed was not in the original container and did not have a pharmacy label. Correction: Medications must be kept in the original labeled container and must include the original pharmacy label. Correct immediately on 5/18/2026. Provide statement of compliance by 5/25/2026. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

Category: health medication. 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.

An expired medication associated with a child's health care plan was observed in room 112. Correction: Medications that are out of date must be picked up or disposed of as required by CDPHE. Corrected at the time of visit by the director removing the medication and disposing of it. NO RESPONSE REQUIRED. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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

2.223.A.2 · The time a child arrives and leaves the center each day must be recorded. Staff members must complete written attendance verification periodically throughout the day, including during transitions.

While in room 112, the staff indicated they had nine (9) children. Licensing specialist counted nine (9) children, but upon review of the name to face sheet, they only accounted for eight (8) children at their 8:30AM, 9:00AM, 9:30AM, 10:00AM, and 10:30AM name to face checks. This is a direct violation of stipulation G of the probationary license: Licensee will use a name-to-face attendance verification tool (paper or electronic form) and complete attendance verification for all transitions and at frequent intervals throughout the day. Licensee shall provide training for all staff on how to use the attendance verification tool and must maintain verification of the training in each employee’s staff file. Correction: Periodic verification of attendance must be completed throughout the day. Correct immediately on 5/18/2026. Provide statement of compliance by 5/25/2026. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

Category: recordkeeping. Marked corrected in the state record.

2.229.B · Window blind cords must be secured out of children's reach to prevent strangulation.

Window blind cords were reachable by children in room 103. Correction: Window blind cords must be secured out of children's reach. Corrected at the time of visit by the director tying the blind cords up and out of reach. NO RESPONSE REQUIRED. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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.

Three (3) small hair clips that fit inside a choke tube were accessible to children in a child's cubby in room 105, which had children under the age of three (3) present. This is a direct violation of stipulation O of the probationary license: Hazardous items, including items labeled “keep out of reach of children,” must be inaccessible to children at all times, both indoors and outside. Choking hazards must be inaccessible to children under three (3) years of age. Correction: Materials accessible to children under three (3) must not pose a choking hazard. Corrected at the time of visit by the director removing the hair clips making them inaccessible. NO RESPONSE REQUIRED. Correct by 05/18/2026

Corrected Corrected by May 18, 2026

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

2.229.C · Items labeled “keep out of reach of children” must be inaccessible to children.

In the Squirrels classroom, Dawn dish soap labeled "keep out of reach of children" was in an unsecured cabinet, accessible to children and posing a potential safety hazard. Correction: All items labeled "keep out of reach of children" must be inaccessible at all times. This is a direct violation of stipulation (O) on the probationary license. Probationary stipulation (O) states, "Hazardous items, including items labeled "keep out of reach of children," must be inaccessible to children at all times, both indoors and outside. Choking hazards must be inaccessible to children under three (3) years of age." **Corrected at time of visit, staff member removed the Dawn dish soap on 4/28/2026.** No response is required. Correct by 04/28/2026

Corrected Corrected by Apr 28, 2026

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

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

In the Butterflies, Flamingo and Squirrels classroom; cords longer than 18 inches were in an unsecured drawer and on a low shelf, accessible to children and posing a potential safety hazard. In the Kangaroo classroom, a personal bag was on the floor in an unsecured closet and in the Flamingo classroom, a personal bag was on the floor next to the teacher's desk. Both personal bags were accessible to children and posing a potential safety hazard. Correction: Keep all indoor and outdoor equipment, materials, and furnishings sturdy, safe and free of hazards. This is a

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

2.237.H · In rooms used by children, all electrical outlets that are accessible to children must have protective covers, or safety outlets must be installed.

In the Flamingo room, observed a power cord next to the sink and one on the floor next to the teacher's desk, uncovered and accessible to children, posing a potential safety hazard. Correction: All electrical outlets that are accessible to children must have protective covers at all times. **Corrected at time of visit, staff member covered the outlets on 4/28/2026.** No response is required. Correct by 04/28/2026

Corrected Corrected by Apr 28, 2026

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

2.229.C · Items labeled “keep out of reach of children” must be inaccessible to children.

In the Hedgehogs classroom, observed a bucket of diaper creams labeled "keep out of reach of children" in an unlocked cabinet accessible to children. Correction: Immediately, items labeled "keep out of reach of children" must be inaccessible. Corrected at the time of the visit. A staff member locked the cabinet making the diaper creams inaccessible to children. No response is required. Correct by 01/12/2026

Corrected Corrected by Jan 12, 2026

Marked corrected in the state record.

2.237.H · In rooms used by children, all electrical outlets that are accessible to children must have protective covers, or safety outlets must be installed.

In the Flamingos classroom, observed an extension cord lacking an outlet cover accessible to children. Correction: Immediately, all electrical outlets that are accessible to children must have protective covers or safety outlets. Corrected at the time of the visit. A staff member placed an outlet cover on the extension cord outlets. No response is required. Correct by 01/12/2026

Corrected Corrected by Jan 12, 2026

Marked corrected in the state record.

2.217.A.14 · Staff to Child Ratios by ages of children and number of staff- 6 weeks to 18 months (infants):1 staff member to 5 infants; 12 months to 36 months: 1 staff member to 5 toddlers; 24 months to 36 months: 1 staff member to 7 toddlers; 2-1/2 years to 3 years:1 staff member to 8 children; 3 years to 4 years: 1 staff member to 10 children; 4 years to 5 years: 1 staff member to 12 children; 5 years and older: 1 staff member to 15 children; Mixed-age group 2-1/2 yrs to 6 yrs: 1 staff member to 10 children.

In the S105 Classroom, observed 1 teacher alone with 19 preschool age children. The proper staff to child ratio is 1 staff member to 12 children. Correction: Immediately, staff to child ratios must be followed. Corrected at the time of the visit. A staff member entered the classroom the maintain the proper ratios. No response is needed. Correct by 11/21/2025

Corrected Corrected by Nov 21, 2025

Category: ratio. 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 11 staff files and observed that 10 staff members were missing documentation of a current health statement signed and dated by a physician/health care provider or had expired self-reported health histories. Correction: Within 30 days, all staff must submit a medical statement signed and dated by a physician or other health care provider within 30 days of employment. Subsequent self-reported health histories must be submitted annually. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 10/12/2025

Corrected Corrected by Oct 12, 2025

Category: health medication. 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 11 staff files and observed that 3 staff members were missing documentation of a current Standard Precautions training. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately, all staff must complete Standard Precautions prior to working with children and must be renewed annually. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 09/12/2025

Corrected Corrected by Sep 12, 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 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 11 staff files and observed that 3 staff members were missing documentation of a current Shaken Baby/Abusive Head Trauma training. Correction: Immediately, staff working with children less than 3 years of age must complete the Shaken Baby/Abusive Head Trauma training prior to working with children and must be renewed every 2 years. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 09/12/2025

Corrected Corrected by Sep 12, 2025

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 11 staff files and observed that 2 staff members were missing documentation of a current abuse prevention training. Correction: Immediately, all employees/regular volunteers must complete the abuse prevention training within 30 days of employment and must be renewed annually. Correct by 09/12/2025

Corrected Corrected by Sep 12, 2025

Category: recordkeeping. Marked corrected in the state record.

2.217.C.8 · All Department-approved child care health consultants must complete the Department- approved Colorado Department of Public Health and Environment immunization course annually. The center must obtain and maintain proof of course completion.

Reviewed the CCHC file and observed that they were missing documentation of a current immunization training. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Within 30 days, CCHC's must complete the immunization course and must renew annually. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 10/12/2025

Corrected Corrected by Oct 12, 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.

Reviewed drill logs and observed that there was no documentation of drills completed within the 2025 year. Correction: Immediately, drills must be completed at the required timeframes and a record must be maintained including the date and time of the drill, number of adults and children participating, and the amount of time taken to evacuate. Submit a written statement of compliance to the Licensing Specialist. Correct by 09/12/2025

Corrected Corrected by Sep 12, 2025

Category: recordkeeping. Marked corrected in the state record.

2.210.A.1 · A record must be maintained, either written or electronic, for each staff member that includes the following: Name, address, telephone number, and birth date of the individual.

Reviewed 18 staff files and observed that Claudia R-S was missing documentation of their name, address, telephone number, and birth date. Correction: Immediately, a record must be maintained including the staff members name, address, telephone number, and birth date. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 09/24/2024

Corrected Corrected by Sep 24, 2024

Category: recordkeeping. Marked corrected in the state record.

2.223.A.2 · The time a child arrives and leaves the center each day must be recorded. Staff members must complete written attendance verification periodically throughout the day, including during transitions.

In the Kangaroos classroom, SM stated that there were 10 children in the classroom. SM verified attendance and identified that there were 9 children in attendance. Reviewed attendance tracker and observed that only 8 children were signed in and 1 child was not. Correction: Immediately, the time a child arrives and leaves the center each day must be recorded and attendance verification must be completed throughout the day. Submit a written statement of compliance to the Licensing Specialist. Correct by 09/24/2024

Corrected Corrected by Sep 24, 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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 18 staff files and observed that Isabel M. was missing documentation of a current abuse prevention training. The training on file expired on 8/9/2024. Correction: Immediately, all empployees and regular volunteers must complete a department-approved training on abuse prevention and must be renewed annually. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 09/24/2024

Corrected Corrected by Sep 24, 2024

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 18 staff files and observed that Roxanne C. was missing documentation of a First Aid/CPR training. Correction: Within 30 days, all employees must complete a department-approved First Aid/CPR training and must be renewed every 2 years. Submit documentation and a written statement of compliance to the Licensing Specialist. Correct by 10/24/2024

Corrected Corrected by Oct 24, 2024

Category: recordkeeping. Marked corrected in the state record.

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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 18 staff files and observed that Tao Z.'s abuse and neglect inquiry was submitted on 12/17/2023 and the results of the abuse and neglect inquiry were not maintained or available for review. 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 Tao Z. has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS for staff members Tao Z. with written response to the Specialist. Correct by 09/24/2024

Corrected Corrected by Sep 24, 2024

Marked corrected in the state record.

2.126.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.

Reviewed 18 staff files and observed that Claudia R-S. was missing documentation of an abuse and neglect acknowledgement. Correction: Immediately, each staff member must reach and sign a statement clearly defining child abuse and neglect pursuant to state law outlining the staff members personal responsibility to report all incidents of child abuse or neglect according to state law. Submit documentation of a written statement of compliance to the Licensing Specialist. Correct by 09/24/2024

Corrected Corrected by Sep 24, 2024

Marked corrected in the state record.

2.219.B.4 · Health statements for children over two (2) years of age to seven (7) years of age must be updated in accordance with the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care schedule for routine well child exams.

Reviewed 8 children's files and observed that 1 child was missing documentation of a current health statement. Correction: Within 30 days, health statements must be updated in accordance with the AAP Recommendations. Submit a writen statement of compliance to the Licensing Specialist. Correct by 10/24/2024

Corrected Corrected by Oct 24, 2024

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

7.702.46.A.15 · Maximum Group Size for Children by AGES OF CHILDREN and MAXIMUM GROUP SIZE: 6 weeks to 18 months: 10 infants 12 months to 36 months: 10 toddlers 24 months to 36 months: 14 toddlers 2-1/2 years to 3 years: 16 children 3 years to 4 years: 20 children 4 years to 5 years: 24 children 5 years and older: 30 Children Mixed age group 2-1/2 to 6 years of age: 20 Children

34 mixed age preschool children on the preschool playground at time of inspection. Correction: Maintain proper group size at all times. Submit plan for compliance with written response to specialist. Correct by 10/02/2023

Corrected Corrected by Oct 2, 2023

Category: ratio. Marked corrected in the state record.

7.701.33.A.1 · Each applicant listed below must submit to the Colorado Bureau of Investigation (CBI) and the Federal Bureau of Investigation (FBI) a complete set of fingerprints taken by a qualified law enforcement agency or any third party vendor approved by CBI including county departments of human or social services that use fingerprint machines pursuant to Section 19-3-406(1)(C),(2), C.R.S., to obtain any fingerprint criminal history record held by the CBI and FBI. If a third party takes the individual’s fingerprints, the fingerprints may be electronically captured using CBI’s approved LiveScan equipment. Payment of the fee for the criminal record check is the responsibility of the individual being checked, identified as follows:

Reviewed 20 staff files and observed no documentation of CBI clearance letter for staff member Nelly. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member Nelly has reviewed the powerpoint within 24 hours. Submit documentation of CBI Clearance Letters for staff member Nelly with written response to Specialist. Correct by 10/02/2023

Corrected Corrected by Oct 2, 2023

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