2.509.B.1 · Each program leader must be at least eighteen (18) years of age, demonstrate ability to work with children, and must have completed at least one (1) of the following qualifications:

Reviewed 3 staff files. Jessica missing documentation of program lead qualifications. Correction: Immediately review all staff files. Program Leads must have completed one of the qualification pathways as

Open Not marked corrected in the state record

Open / not marked corrected.

2.508.D · Within (30) calendar days of employment all staff members and regular volunteers must complete 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 know child abuse or neglect. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 3 staff files. Jesus missing documentation of a current child abuse prevention training. Correction: Immediately review all staff files. All staff must complete and renew annually the child abuse prevention training. Submit documentation and a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Category: recordkeeping. Marked corrected in the state record.

2.508.F · For every thirty (30) or fewer children in attendance, there must be at least one (1) staff member who holds current Department-approved First Aid and Safety certification including CPR for all ages of children. Such FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ individuals must be with the children at all times when the center is in operation. If children are at different locations, there must be a First Aid and CPR certified staff member at each location.

Reviewed 3 staff files. At the time of visit, missing documentation of at least 1 staff person with a current CPR and First Aid certification on site during operating hours. Correction: Immediately review all staff files. for every 30 or fewer children in attendance, there must be one staff member with a current CPR and First Aid certification with the children at all times. Submit documentation and a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Category: ratio. Marked corrected in the state record.

2.508.K · All staff in building-based school-age child care centers who work with children must complete a minimum of fifteen (15) clock hours of ongoing professional development each year, beginning with the start date of the employee. At least three (3) clock hours per year must be in the focus of social emotional development.

Reviewed 3 staff files. Jessica & Jesus missing documentation of ongoing professional development clock hours that includes at least 3 clock hours of social emotional development. Correction: Review all staff files. All staff must have documentation of ongoing professional development clock hours on file and available for review at all times. Submit a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Marked corrected in the state record.

2.509.A.2 · The program director must be at least twenty-one (21) years of age, and must have completed at least one (1) of the following qualifications:

Reviewed 3 staff files. Jesus missing documentation of program director qualifications. Correction: Immediately review all staff files. Program Directors must have completed one of the qualification pathways as required by licensing rules and documentation must be available for review at all times. Submit documentation and a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Marked corrected in the state record.

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

Reviewed 3 staff files. At the time of visit, the facility was missing documentation of at least one staff member with a completed and current medication administration training. Correction: Immediately, there must be at least 1 staff member with a current medication administration training on duty at all times. Submit documentation and a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Category: ratio. Marked corrected in the state record.

2.527.D · Combustibles, such as cleaning rags, mops, and cleaning compounds, must be stored in well-ventilated areas separated from flammable materials and stored in areas inaccessible to children.

At the time of visit, the door to the janitor office was opened and cleaning compounds were accessible to children, and a mop bucket with cleaning solution and used mop was in the cafeteria by the windows and accessible to children. Correction: Immediately, combustibles, such as cleaning rags, mops, and cleaning compounds must be inaccessible to children at all times. Submit a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

Marked corrected in the state record.

2.530.A.6 · 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 health history including any health care plans, which indicates communicable diseases, and chronic illnesses or injuries the individual has had, immunization record or exemption status, any known drug reactions or allergies, medications being taken, and any necessary health procedures or special diet needs;

Reviewed 7 child files. 2 children missing documentation of a current health history. Correction: Immediately review all child files. All child files must have a completed health history updated annually. Submit

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

2.530.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: An annual written authorization for emergency medical care signed and dated submitted by the parent(s) or guardian(s). The authorization must be notarized if required by the local hospital, clinic, or emergency health care facility;

Reviewed 7 child files. 3 children missing documentation of a written authorization for emergency medical care. Correction: Immediately review all child files. All children must have a written authorization for emergency medical care signed and dated by the parent(s) or guardian(s) that is updated annually on file at all times. Submit a written statement of compliance by 4/6/2025. Correct by 03/06/2025

Corrected Corrected by Mar 6, 2025

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

2.133.A · Prior to caring for children, all staff must complete a Department-approved training in emergency and disaster preparedness: Evacuation, Shelter in Place, Lockdown, and Active Shooter on Premises Plans for Children in Care. For seasonal children’s resident camp programs, operating no more than 90 days per calendar year, at least one on site director must be trained in the Department approved training.

Reviewed 4 staff file. Observed Jayden R. hired on 4/1/2024 missing documentation of a Department-approved training in emergency and disaster preparedness. Correction: Prior to caring for children, staff must complete a Department-approved training in emergency and disaster preparedness. Submit documentation and a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. 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 the Emergency drill log. Observed missing tornado drills from March and missing lockdown drill from the last quarter of 2023 and the first quarter of 2024. Correction: Immediately, lockdown drills must be held at least quarterly and tornado drills must be held monthly from March-October. Submit a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.I · All staff members must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 4 staff files. Observed Crystal S., Jessica C. and Jayden R. missing current documentation of a Department-approved standard precautions training. Correction: Immediately, all staff members must complete a Department-approved standard precautions training prior to working with children. Submit documentation and a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.L · All staff members and regular volunteers must complete a Department-approved training about child abuse prevention, including common symptoms and signs of child abuse within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 4 staff files. Observed Jessica C. hired 3/27/2023, missing current documentation of a Department-approved training about child abuse prevention. Correction: All staff must complete a Department-approved training about child abuse prevention within thirty (30) calendar days and renewed annually. Submit documentation and a written statement of compliance by 5/12/2024. Correct by

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

2.133.A · Prior to caring for children, all staff must complete a Department-approved training in emergency and disaster preparedness: Evacuation, Shelter in Place, Lockdown, and Active Shooter on Premises Plans for Children in Care. For seasonal children’s resident camp programs, operating no more than 90 days per calendar year, at least one on site director must be trained in the Department approved training.

Reviewed 4 staff file. Observed Jayden R. hired on 4/1/2024 missing documentation of a Department-approved training in emergency and disaster preparedness. Correction: Prior to caring for children, staff must complete a Department-approved training in emergency and disaster preparedness. Submit documentation and a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. 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 the Emergency drill log. Observed missing tornado drills from March and missing lockdown drill from the last quarter of 2023 and the first quarter of 2024. Correction: Immediately, lockdown drills must be held at least quarterly and tornado drills must be held monthly from March-October. Submit a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.I · All staff members must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 4 staff files. Observed Crystal S., Jessica C. and Jayden R. missing current documentation of a Department-approved standard precautions training. Correction: Immediately, all staff members must complete a Department-approved standard precautions training prior to working with children. Submit documentation and a written statement of compliance by 5/12/2024. Correct by 04/12/2024

Corrected Corrected by Apr 12, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.L · All staff members and regular volunteers must complete a Department-approved training about child abuse prevention, including common symptoms and signs of child abuse within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 4 staff files. Observed Jessica C. hired 3/27/2023, missing current documentation of a Department-approved training about child abuse prevention. Correction: All staff must complete a Department-approved training about child abuse prevention within thirty (30) calendar days and renewed annually. Submit documentation and a written statement of compliance by 5/12/2024. Correct by

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.