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.

Program lacking documentation of the drill type for October and November 2023, January, February and March 2024. Program lacking documentation of fire drills being held monthly within the last 12 months and lacking documentation of monthly tornado drills within the last 12 months during the months of March - October. Correction: Provide a written statement of compliance ensuring that all required drills are documented within the required timeframes that includes monthly fire drills, monthly tornado drills during the months of March through October and quarterly lockdown drills to include active shooter, as well as documentation for each drill with the date, time, type of drill, duration of each drill, along with the number of staff and number of children present during the each drill. Correct by 11/05/2024

Corrected Corrected by Nov 5, 2024

Category: recordkeeping. Marked corrected in the state record.

7.702.42.A · . All staff must complete a pre-service Building and Physical Premises Safety training prior to working with children. The training must include identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, vehicular traffic handling and storage of hazardous materials and the appropriate disposal of biological contaminants.

Reviewed 1 staff file and observed the program lacking documentation of the completed Pre Service Building and Physical Premsies Safety training for Tracy S. Correction: Immediately (09/14/2023) ensure that all staff to include the above listed staff has been trained on the program's building and physical premises safety plan and documentation be maintained. Provide a written statement of compliance within the overall response. Correct by 09/14/2023.

Corrected Corrected by Sep 14, 2023

Category: recordkeeping. Marked corrected in the state record.

7.702.42.B · All staff must complete a Department-approved Standard Precautions training that meets current FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Occupational Safety and Health Administration (OSHA) requirements prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 1 staff file and observed the program lacking documentation of the completed Standard Precautions training that includes the review of the program's exposure control plan for Tracy S. Correction: Immediately (09/14/2023) esnure that all staff to include the above listed staff completes the required standard precautions training to include the review of the program's exposure control plan. Provide a written statement of compliance within the overall response. Correct by 09/14/2023.

Corrected Corrected by Sep 14, 2023

Category: ratio. Marked corrected in the state record.

7.701.33.J.1.a.b.c · The following background check requests must be submitted and successfully completed for each state an individual has resided in, in the past five years, 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: a. State criminal history check b. State sex offender registry check c. State abuse and neglect registry check

Program lacking documentation of the completed State Based Background Check Checklist for Tracy S. that indicates if the employee has resided outside of Colorado within the past 5 years. Correction: Within 24 hours (09/15/2023) provide documentation and ensure that the State Based Background Check checklist has been completed for the above listed staff and any follow up requests have been initiated if applicable. Also ensure that the Colorado BIU Background Check Powerpoint presentation is reviewed by all staff. Provide a written statement of compliance within the overall response. . Correct by 09/15/2023

Corrected Corrected by Sep 15, 2023

Category: supervision. Marked corrected in the state record.

7.702.42.A · - All staff must complete a pre-service Building and Physical Premises Safety training prior to working with children. The training must include identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, vehicular traffic handling and storage of hazardous materials and the appropriate disposal of biological contaminants.

Reviewed 1 staff and observed the program lacking documentation of the completed Pre Service Building and Physical Premises safety plan training (Anna S. ). Correction: Immediately ensure that all staf prior to working with children complete the pre service Building and Physical Premises Safety trainining. Provide a written statememt of compliance within the overall response. Correct by: 08/17/2023

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

7.701.33.J.1.a.b.c · The following background check requests must be submitted and successfully completed for each state an individual has resided in, in the past five years, prior to an individual caring for children or allowing the FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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: a. State criminal history check b. State sex offender registry check c. State abuse and neglect registry check

Reviewed 1 staff file and observed the program lacking documentation of a completed State Based Check Checklist indicating potential residency outside of Colorado within the past 5 years (Anna S,). Correction: WIthin 24 hours (08/18/2023) provide documentation of the completed State Based Background check checklist for Anna S., along with reviewing the BIU Background Check powerpoint presentation. Provide a written statement of compliance within the overall response. Correct by 08/18/2023

Corrected Corrected by Aug 18, 2023

Category: supervision. Marked corrected in the state record.

7.701.52.D.2 · . Changes to a License Requiring Written Notification to the Department Prior to Department Approval - Changes in the physical facility or use of rooms for child care at a facility.

Use of room #303 for nap/rest time without prior approval from the Department. Correction: Immediately (07/13/2023) ensure that all rooms used for children have prior written approval from the Department prior to use of the room. Provide documentation for the change request/application, along with a written statement of compliance within the overall response. Correct by 07/13/2023

Corrected Corrected by Jul 13, 2023

Marked corrected in the state record.