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 23 staff files and found 2 staff working with children under 3 to be missing documentation of current training in shaken baby. Correction: All staff working with children under 3 must complete a training in shaken baby. Correct and provide a written statement of compliance. Correct by 04/30/2026

Corrected Corrected by Apr 30, 2026

Category: recordkeeping. Marked corrected in the state record.

2.213.G · All employees and regular volunteers must be trained using a Department-approved training about Child Abuse Prevention prior to working with children, 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 23 staff files and found 1 to be missing documentation of a current training in abuse prevention. Correction: All staff must complete a training in abuse prevention and must update annually. Correct and provide a written statement of compliance. Correct by 04/30/2026

Corrected Corrected by Apr 30, 2026

Category: recordkeeping. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 23 staff files and found 8 to be missing a signed medical statement. Correction: All staff must submit a signed medical statement within 30 days of employment. Correct and provide a written statement of compliance. Correct by 05/30/2026

Corrected Corrected by May 30, 2026

Category: health medication. 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.

There was an outlet in the multipurpose area that did not have a protective cover. Correction: All outlets accessible to children must have protective covers. Correct and provide a written statement of compliance. Correct by 04/30/2026

Corrected Corrected by Apr 30, 2026

Marked corrected in the state record.

2.216.B.2.b · The infant program supervisor or an infant early childhood teacher must be assigned to each group of ten (10) or fewer infants in attendance. An infant program staff aide may be assigned to assist the infant program supervisor or the infant early childhood teacher when six (6) through ten (10) infants are in care in the group to maintain the staff ratio of one (1) adult for each five (5) infants.

The Infant Supervisor (IPS) was out of the infant room. During the file review it was observed that there was not a qualified infant teacher in the classroom. Correction: In the infant program there must be an IPS or Infant Early childhood teacher must be assigned to each group of 10 or fewer infants. Correct and provide a written statment of compliance. Correct by 04/30/2026

Corrected Corrected by Apr 30, 2026

Category: supervision. Marked corrected in the state record.

2.120.D · The Trails child abuse and neglect records request must be made within ten (10) calendar days of the first day of employment for each employee or facility on the state-prescribed form, accompanied by the required fee.

Reviewed 23 staff files and found 2 staff to be missing documentation of a Trails background request. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

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 23 staff files and identified 2 files with FBI clearance documentation older than 5 years. 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 (CBI, FBI, TRAILS, Or Out of State background check, Out of State Clearance Letters) for staff members with written response to the Specialist. Correct by 05/14/2026

Corrected Corrected by May 14, 2026

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

2.121.D · Each owner and employee sixteen (16) years of age or older of a facility or agency shall complete the fingerprint process at an approved vendor. Payment of the fee for the criminal record check is the responsibility of the individual being checked or the facility or agency. The results of the criminal record check, the CBI and/or Federal Bureau of Investigation (FBI) response letters, must be maintained at the home, center, facility, or agency and must be available for review upon request by a Licensing Specialist.

Reviewed 23 staff files and found 2 staff to missing documentation of completion of the criminal background checks. 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 (CBI, FBI, TRAILS, Or Out of State background check, Out of State Clearance Letters) for staff members with written response to the Specialist. Correct by 04/30/2026

Corrected Corrected by Apr 30, 2026

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