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

A red trike on the playground to be missing covers on the handle bars, posing a potential safety hazard. Correction: Outdoor materials must be safe and free of hazards, correct immediately 9/20/24. *Corrected at the time of inspection, Director replaced the covers on the handle bars. No response is required. Correct by 09/20/2024

Corrected Corrected by Sep 20, 2024

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

2.511.B.3.b · The staff working with a child with a health care plan must be informed, trained, and delegated responsibility for carrying out the health care plan by the Department-approved Child Care Health Consultant; supervision of the plan and interventions must be documented.

Staff member reported they did not review, nor was the staff member trained on child's health care plan. Correction: Staff working with a child who has a health care plan must be informed and trained on the health care plan,

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

Cement that is uneven on the walking path in two areas, posing a potential safety hazard. Correction: Outdoor material must be safe and free of hazards, correct immediately 9/20/24. Correct by 09/20/2024 Stage II Licensing Concern : Staff member did not see exactly what happened when the child fell. - FOUNDED

Corrected Corrected by Sep 20, 2024

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

2.510.H · At all times, school-age child care personnel must be directly supervising the children.

Staff member had 2 children with them and did not see what happened to a child when they fell. Correction: At all times, personnel must be directly supervising the children, correct immediately 9/20/24. Correct by 09/20/2024 Stage II Licensing Concern : Facility refused to show caseworker information that was requested. - FOUNDED

Corrected Corrected by Sep 20, 2024

Category: supervision. Marked corrected in the state record.

2.126.D.2 · An agency or facility must not interfere or refuse to cooperate with a child protection investigation.

Materials requested were not given during the investigation. Correction: Facility must not refuse to cooperate with an investigation, correct immediately 9/20/24. Correct by 09/20/2024 Stage II Licensing Concern : Staff pattern was not available for review. Facility does not know what staff were present on the day of the injury. - FOUNDED

Corrected Corrected by Sep 20, 2024

Marked corrected in the state record.

2.529.A.2 · The following records must be on file at the center: A list of current staff members, substitutes, and staffing patterns for the past twelve (12) months must be on file at the center either in written or electronic form. The previous two (2) years must be on file at either the center, a central location, or storage.

Facility was not able to produce staffing patterns when requested. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Staffing patterns must be on file for the past 12 months, correct immediately 9/20/24. Correct by 09/20/2024 ________________________________________________ Stage II Licensing Concern : Child was pulled when child fell on the walkway. - UNFOUNDED Stage II Licensing Concern : Facility did not report the injury to the parents in a timely manner. Facility did not follow policies regarding notifying parents of in injury. - UNFOUNDED Stage II Licensing Concern : Staff are underqualified. - UNFOUNDED Stage II Licensing Concern : Staff are not trained appropriately. - UNFOUNDED Stage II Licensing Concern : Children are running out of the facility. - UNFOUNDED Stage II Licensing Concern : Facility reported false information to the department. - UNFOUNDED ________________________________________________

Corrected Corrected by Sep 20, 2024

Category: recordkeeping. Marked corrected in the state record.

2.524.A.7 · Indoor and outdoor equipment, materials, and furnishings must be sturdy, safe and free of hazards.

A red trike and a yellow trike on the playground to be missing handle bar covers, posing a potential safety concern. Correction: Outdoor materials must be free of hazards, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 2024

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

2.509.C · There must be at least one (1) program leader providing supervision with each group of thirty (30) or fewer children cared for by the center. When four- (4) year-olds are in attendance, there must be at least one program leader providing supervision with each group of twenty-four (24) or fewer children cared for by the center.

During the walk through, there were staff that are not program lead qualified alone with a small group of children. The program has an appeal that program leader staff must have a minimum of 350 hours. Only 2 staff had program lead qualifications. *This is a direct violation of stipulation "C" on the probationary license. Correction: There must be at least one program leader with each group of children, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 2024

Category: supervision. Marked corrected in the state record.

2.118.C.3 · If, after the Department approves a hardship appeal or materials waiver request, the applicant or licensee violates the terms and conditions described in the approved alternate compliance plan, approved safety policy, or official decision letter, the Department’s approval will immediately be rescinded and considered null and void. For purposes of this provision, any injuries, accidents, or founded complaints or investigations related to the appealed or waived licensing rule constitute a violation.

The program has a hardship waiver that reads: "Each program leader must be at least 18 years of age, demonstrate ability to work with children, and must meet the following qualifications: Must have at least three (3) months (460 hours) of full-time or equivalent part-time satisfactory and verifiable experience with school-age children" Several staff alone with a group of children did not have the 350 required hours. Correction: Program must comply with the appeal conditions, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 2024

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), 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 11 staff files and observed Bella J and Anjing H to be missing a child abuse and neglect check (TRAILS). *This is a direct violation of stipulation "L" on the probationary license. Correction: 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 Specialist. Correct by 07/10/2024

Corrected Corrected by Jul 10, 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 11 staff files and observed Nora J to be missing a CBI letter and to be working with children. *This is a direct violation of stipulation "L" on the probationary license. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff member has reviewed the powerpoint within 24 hours. Submit documentation of (CBI) for staff member with written response to Specialist. Correct by 07/10/2024

Corrected Corrected by Jul 10, 2024

Category: supervision. Marked corrected in the state record.

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.

No fire inspection was available to review. Correction: Obtain current fire inspection, correct by 8/9/24. Document compliance to specialist by 8/9/24. Correct by 08/09/2024

Corrected Corrected by Aug 9, 2024

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ amount of time taken to evacuate.

No active shooter/lock down drills were completed. Correction: Emergency drills must be conducted according to rule, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 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 11 staff files and observed Maggie S, and Claire O to be missing a department approved standard precautions training and Nora J and Ida T to be missing the required 2nd signature on the certificate. *This is a direct violation of stipulation "J" on the probationary license. Correction: Obtain current, completed standard precautions training for staff, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 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 11 staff files and observed Claire O and Ida T to have expired department approved child abuse prevention training. *This is a direct violation of stipulation "J" on the probationary license. Correction: Obtain the department approved child abuse prevention training for staff, correct immediately 7/9/24. Document compliance to specialist by 8/9/24. Correct by 07/09/2024

Corrected Corrected by Jul 9, 2024

Category: recordkeeping. Marked corrected in the state record.

2.124.A.3.b · 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.

The children to be using the Gallery as a licensed space for children. The space is not licensed. Correction: Changes in use of rooms/physical space must be submitted to the department, correct immediately 6/13/24. Document compliance to specialist by 6/20/24. Correct by 06/20/2024

Corrected Corrected by Jun 20, 2024

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 5 staff files and observed Alice B. (DOH 1/24) to be missing a cpr/first aid module. Correction: Obtain a department approved first aid/cpr module for staff, correct by 4/11/24. Document compliance to specialist by 4/11/24. Correct by 04/11/2024

Corrected Corrected by Apr 11, 2024

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 5 staff files and observed Alice B (DOH 1/24) to be missing a department approved training about child abuse prevention. Correction: Obtain a department approved training about child abuse prevention, correct by 4/11/24. Document compliance to specialist by 4/11/24. Correct by 04/11/2024

Corrected Corrected by Apr 11, 2024

Category: recordkeeping. Marked corrected in the state record.

2.133.B · Each staff member of the facility must be trained in fire safety and the use of available fire extinguishers and fire alarms

Reviewed 5 staff files and observed all staff missing training in fire safety and fire extinguishers. Correction: Obtain a training for staff in fire safety and the use of available fire extinguishers, correct immediately 3/11/24. Document compliance to specialist by 4/11/24. Correct by 03/11/2024

Corrected Corrected by Mar 11, 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.

Reviewed 5 staff files and observed 4 staff to be employed longer than 90 days and to be missing a child development training. Correction: Obtain child development trainings for staff, correct by 4/11/24. Document compliance to specialist by 4/11/24. Correct by 04/11/2024

Corrected Corrected by Apr 11, 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 5 staff files and observed Alice V to be missing a department approved standard precautions training. Correction: Obtain a department approved standard precautions training for staff, correct immediately 3/11/24. Document compliance to specialist by 4/11/24. Correct by 03/11/2024

Corrected Corrected by Mar 11, 2024

Category: recordkeeping. Marked corrected in the state record.

2.126.D.2 · An agency or facility must not interfere or refuse to cooperate with a child protection investigation.

Identified through staff statements that management conducted their own investigation after a reportable incident. Correction: A facility must not interfere with a reportable incident, correct immediately 1/18/24. Document compliance to specialist by 1/25/24. Correct by 01/18/2024 ________________________________________________ Stage II Licensing Concern : Staff member scratched Ch1, Staff member grabbed a child by the arm. Staff member inappropriately touched Ch1. - UNFOUNDED Stage II Licensing Concern :

Corrected Corrected by Jan 18, 2024

Marked corrected in the state record.

2.524.A.1 · Buildings must be kept in good repair and maintained in a safe condition.

A column in the teen room by the kitchen to have broken material, posing a potential safety hazard. Correction: Buildings must be maintained in a safe condition, correct immediately 1/17/24. Document compliance to specialist by 1/24/24. Correct by 01/17/2024

Corrected Corrected by Jan 17, 2024

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

7.712.52.B.1 · Written authorization for emergency medical care must be in the child's file as required in Section 7.712.81.

Reviewed 3 child files and observed one child to have an expired emergency medical authorization form. Correction: Obtain a current emergency medical authorization form, correct immediately 11/9/23 or prior to child's next day in attendance. Document compliance to specialist by 11/16/23. Correct by 11/09/2023

Corrected Corrected by Nov 9, 2023

Marked corrected in the state record.