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.

Reviewed nine (9) staff files. The Trails child abuse and neglect background check available for review at the time of inspection for staff members K.S., R.C., and E.B. was completed more than five (5) years ago. Correction: 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 Docusign Envelope ID: 96C4ECD9-3DB0-4E2C-B486-E2BC66445173

Open Not marked corrected in the state record

Category: background checks. 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 nine (9) staff files. The most recent department-approved child abuse prevention training completed by staff members M.W. and T.P. available for review at the time of inspection was completed over one (1) year ago. The child abuse prevention training expired on 9/11/2024 for staff member M.W. and expired on 7/19/2024 for staff member T.P. Correction: All staff members and regular volunteers must complete a Department-Approved training about child abuse prevention. The training must be renewed annually. Correct immediately and document compliance to the Department in your written response. Please provide documentation that staff members M.W. and T.P. have completed a current child abuse prevention training with your response. Correct by 09/23/2024

Corrected Corrected by Sep 23, 2024

Category: recordkeeping. Marked corrected in the state record.

2.508.F.1 · Within thirty (30) calendar days of employment 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 Docusign Envelope ID: 96C4ECD9-3DB0-4E2C-B486-E2BC66445173 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ (30) calendar days of employment and the module must be renewed every two (2) years.

Reviewed nine (9) staff files. The files for staff members R.C. and R.O. did not contain documentation of unexpired First Aid and CPR certification or the First Aid and CPR PDIS module at the time of inspection. The CPR/First Aid certification for staff member R.C. expired on 9/18/2023 and they have not completed the PDIS module. The CPR/First Aid certification for staff member R.O. expired 8/27/2024 and the PDIS First Aid and CPR module expired 7/9/2024. Correction: 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. The module must be renewed every two (2) years. Correct and document compliance to the Department In your written response. Please provide documentation of a current CPR and First Aid certification or documentation that the PDIS CPR and First Aid module has been completed and is current for staff members R.C. and R.O. with your written response. Correct by 10/23/2024

Corrected Corrected by Oct 23, 2024

Marked corrected in the state record.

7.701.34.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.

The most recent fire safety inspection conducted by the local fire department available for review at the time of inspection expired 7/15/2022. Correction: 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. Correct and document compliance to the Department in your response. Correct by 10/27/2023

Corrected Corrected by Oct 27, 2023

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

7.701.32.E · . The 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 paid by check or money order (for fee assessment see Section 7.000.73).

Reviewed nine (9) staff files. No evidence was available at the time of inspection that staff member L.J. had submitted a request or obtained a clearance letter for the Trails Abuse and Neglect background check. Correction: 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 paid by check or money order (for fee assessment see Section 7.000.73). Correct immediately and notify your licensing specialist of the correction plan within 24 hours. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage PowerPoint. Submit verification that staff member L.J. has reviewed the PowerPoint within 24 hours. Submit documentation of TRAILS Clearance Letters for staff member L.J. with your written response to the Specialist. Correct by 09/27/2023

Corrected Corrected by Sep 27, 2023

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

7.701.100.F.2 · . 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.

No documentation of emergency drills, lockdown drills, or active shooter on-premises drills was available at the time of inspection. Correction: 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 DocuSign Envelope ID: 45071FB1-877F-4FB3-9467-B31098064B77

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.