2.122.A · Prior to the original license being issued, following the renovation of the facility that would affect the licensing of the facility and at least every two (2) years thereafter, all child care facilities except family child care homes and Neighborhood Youth Organizations must be inspected and obtain an approving inspection report from the local department of health or the Colorado Department of Public Health and Environment and from the local fire department. These reports must be maintained at the facility and be available for review upon request by a Licensing Specialist.

Observed the program's health inspection to be expired (10/8/2023) and the program to be missing documentation of a current passing fire inspection. Correction: Obtain and provide documentation of a current passing fire and health inspection. Correct and submit documentation with overall response by 6/1/24. Correct by 06/01/2024

Corrected Corrected by Jun 1, 2024

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

2.508.G.1 · For every thirty (30) or fewer children in attendance, there must be at least one (1) staff member FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ who holds current Department-approved First Aid and CPR certificate for all ages of children. Such 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 qualified staff member at each location.

Reviewed 4 staff files and identifed that only one staff member is certified in First Aid and CPR, and the facility is licensed for 45 children. Correction: Obtain documentation of a Department approved First Aid and CPR for at least one more staff member that is with the children at all times. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: ratio. 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.

Observed the program to not have documentation of any emergency drills for the 2023-24 school year. Correction: All drills must be held in accordance with rule. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: recordkeeping. Marked corrected in the state record.

2.508.D.5 · All Child Care Health Consultants must show evidence they have completed the Colorado Department of Public Health and Environment (CDPHE) immunization course annually.

Observed the Child Care Health Consultant's CDPHE Immunization training to be expired (9/27/2023). Correction: Obtain documentation of a current Department approved CDPHE Immunization training for the Child Care Health Consultant. Correct and submit written statement of compliance with overall response by 6/1/24. Correct by 06/01/2024

Corrected Corrected by Jun 1, 2024

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

2.507.K · All staff member responsible for the collection, review and maintenance of the child immunizations records must show evidence they have completed the Colorado Department of Public Health and Environment (CDPHE) immunization course within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Observed the person responsible for the collection, review and maintenance of the childrens immunization FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ records, M. Gonzales, to be missing documentation of a Department approved CDPHE Immunization course. Correction: Obtain documentation of a Department approved CDPHE Immunization course for the staff member listed above. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

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 files and observed two staff members, M Gonzales and L Nelson, to be missing documentation of a Department approved training in emergency and disaster preparedness prior to working with children. Correction: Obtain documentation of a Department approved training in emergency and disaster preparedness for the staff members listed above. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: recordkeeping. Marked corrected in the state record.

2.507.M · All staff must have at least one (1) hour of child development training within ninety (90) days of employment. This training must include the major domains (cognitive, social, emotional, physical development and approaches to learning). This training is required once and will count toward ongoing training requirements if taken after the date of hire. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 4 staff files and observed four staff members, M Gonzales, L Nelson, C Gray and M Hubbard to be missing documentation of 1 hour of child development training within 90 days of employment. Correction: Obtain documentation of a 1 hour of child development training for the staff members listed above. Correct and submit written statement of compliance with overall response by 6/1/24. Correct by 06/01/2024

Corrected Corrected by Jun 1, 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 and observed 1 staff member, M Gonzales, to be missing documentation of child abuse prevention training within 30 days of employment. Correction: Obtain documentation of a Department approved child abuse prevention course for the staff member listed above. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: recordkeeping. Marked corrected in the state record.

2.512.A.1.b · At the time of enrollment, the parent(s)/guardian(s) must provide for each child entering the center: Documentation of school-required immunization status or Certificate of Medical or Nonmedical Exemption, is required by the Colorado Board of Health. Up-to-date school-required immunizations must be documented as specified on the Colorado Department of Public Health and Environment Certificate of Immunization or on an “approved alternate” Certificate of Immunization, defined in Colorado Department of Public Health and Environment regulation at 6 CCR 1009-2:VI(A), (May 15, 2023), no later editions or amendments are incorporated. These regulations are available from the Colorado Department of Public Health and Environment at no cost at https://www.coloradosos.gov/CCR/Welcome.do. These regulations are also available for public inspection and copying at the Colorado Department of Early Childhood, 710 S. Ash St., Denver, CO 80246, during regular business hours. Colorado law requires proof of immunization status or exemption be provided prior to or on the first day of admission.

Reviewed 4 children's files and observed the program to be missing documentation of immunization status for 3 children and 1 child to have immunizations, but not on the Department approved CDPHE form. Correction: Obtain immunizations for all children in care on the Department approved CDPHE form. Correct immediately

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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 and observed two staff members, M Gonzales, and L Nelson, to be missing documentation of a Standard Precautions training prior to working with children and one staff member, C Gray, to have an expired (7/24/23) Standard Precautions training. Correction: Obtain documentation of a current, Department approved Standard Precautions training for the staff members listed above. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: recordkeeping. Marked corrected in the state record.

2.508.B.2 · Program Leaders Each program leader must be at least eighteen (18) years of age, demonstrate ability to work with children, and must meet the following qualifications: Complete the Department-approved course in playground safety for School-Aged Child Care Centers. This requirement does not apply to day camps that do not regularly use a playground; and

Reviewed 4 staff files and identified that M Hubbard is a program leader and is missing documentation of a current, Department approved course in playground safety for School-Aged Child Care Centers. Correction: Obtain documentation of a Department approved course in playground safety for School-Aged Child Care Centers for the staff member listed above. Correct and submit written statement of compliance with overall response by 6/1/24. Correct by 06/01/2024

Corrected Corrected by Jun 1, 2024

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

2.120.C.1.a · The Trails child abuse or neglect records request must be made on the state-prescribed form, accompanied by the required fee within the following required time frames: Child care centers (less than 24-hour care), FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ school-age child care facilities, family child care homes, and qualified exempt providers must meet the following: For all individuals whose activities involve the care or supervision of children or who have unsupervised access to children, requests must be submitted and successfully completed prior to caring for children or allowing unsupervised access to children.

Reviewed 4 staff files and observed 2 employees, M Gonzales and L Nelson, to be missing documentation of a Trails Child Abuse and Neglect clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members M Gonzales and L Nelson have reviewed the powerpoint within 24 hours. Submit documentation of TRAILS background check for staff members M Gonzales and L Nelson with written response to Specialist. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: supervision. Marked corrected in the state record.

2.121.D.4.a · Criminal background check requests must be successfully completed 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-age child care facilities, family child care homes, and qualified exempt provider homes.

Reviewed 4 staff files and observed 2 employees, M Gonzales and L Nelson, to be missing documentation of a FBI clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members M Gonzales and L Nelson have reviewed the powerpoint within 24 hours. Submit documentation of FBI background check for staff members M Gonzales and L Nelson with written response to Specialist. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Category: supervision. Marked corrected in the state record.

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

Reviewed 4 staff files and observed 1 employee, M Hubbard to not have an updated Trails clearance letter within the last 5 years. The current clearance letter is dated 3/6/2019. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members M Hubbard has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS background check for staff members M Hubbard with written response to Specialist. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

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.

Reviewed 4 staff files and observed 1 employee, M Hubbard to not have an updated FBI clearance letter within the last 5 years. The current clearance letter is dated 8/31/2018 Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member M Hubbard has reviewed the powerpoint within 24 hours. Submit documentation of FBI background check for staff members M Hubbard with written response to Specialist. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

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

2.507.G · The center must have a staff development plan that includes a minimum of fifteen (15) clock hours of ongoing training each year for all staff. This requirement does not apply to day camps. At least three (3) clock hours per year must be in the focus of social emotional development. The fifteen (15) clock hours of training does not include recertification in First Aid and CPR. Ongoing training and courses must demonstrate a direct connection to one or more of the following competency areas:

Reviewed 4 staff files and observed 2 staff members, M Hubbard and C Gray, to be missing documentation of 15 hours of ongoing training for the year, including 3 clock hours of social emotional development. Correction: Obtain documentation of 15 hours of ongoing training for the year, including 3 clock hours of social emotional development for the staff members listed above. Correct and submit written statement of compliance with overall response by 6/1/24. Correct by 06/01/2024

Corrected Corrected by Jun 1, 2024

Category: recordkeeping. Marked corrected in the state record.

2.508.G.3 · All employees caring for children, not required by rule to be certified in First Aid and CPR, must complete a Department-approved basic First Aid and CPR module within thirty (30) calendar days of employment and the module must be renewed every two (2) years.

Reviewed 4 staff files and observed 1 staff member, M. Gonzales, to be missing documentation of a Department approved CPR and First Aid certification or module within 30 days of employment. Correction: Obtain documentation of a Department approved CPR and First Aid certification or module. Correct immediately by 5/1/24 and submit written statement of compliance with overall response by 6/1/24. Correct by 05/01/2024

Corrected Corrected by May 1, 2024

Marked corrected in the state record.