2.509.D · The maximum group size for children over the age of five (5) is thirty (30) children. When four (4) year olds are in attendance the maximum group size is twenty-four (24). When the center has the capacity to care for multiple groups of children, they must be separated into developmentally and age appropriate activities. Groups are not required to be separated from each other by permanent or portable dividers or walls.

Upon arrival to the facility, Licensing Specialist observed 73 children all together on the playground. Correction: The maximum group size for children 5 years of age and up, is 30 children. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: ratio. 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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Observed the facility to be missing documentation of a current, passing health and fire inspection. Correction: Obtain and provide documentation of a current, passing health and fire inspection for the facility. Correct immediately by 8/29/24 and submit documentation with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

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

2.507.N · Prior to working with children, each staff member must read and be trained on the center’s policies and procedures for the administration of medications. Staff members must sign a statement indicating that they have read and have been trained on the center's administration of medications policies and procedures.

Reviewed 8 staff files and observed all 8 staff members to be missing documentation of a statement indicating that they have read and have been trainined on the facility's medication admininistration policies and procedures. Correction: Obtain documentation of a statement indicating that staff have read and been trained on the facility's med admin policies and procedures. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: ratio. 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 8 staff files and observed 7 staff members to be missing documentation of a Child Development training. Correction: Obtain documentation of a Child Devlopment training for the staff missing it. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. 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.

Reviewed 8 staff files and observed, Ashley Packard, the staff member responsible for the collection, review and maintenance of the children's immunizations to be missing documentation of a current, Department approved CDPHE Immunization training. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Obtain documentation of a Department approved CDPHE immunization training for the staff member missing it. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

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

2.507.J · All staff members must complete a building and physical premises safety training prior to working with children. The training must include:

Reviewed 8 staff files and observed 4 staff members (Jake Owens, Charlotte Granrud, Isiah Broce, Rian Owens) to be missing documentation of a building and physical premises safety training prior to working with children. Correction: Obtain documentation of a building and physical premises safety training prior to working with children for the staff members listed above. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 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 8 staff files and observed 4 staff members (Ashley Packard, Charlotte Granrud, Rian Owens, Anastasia Ader) to be missing documentation of a Standard Precautions training and 2 staff members (Isiah Broce & Anna Johnson) to be missing a signature on their certificates indicating that the exposure control plan has been reviewed with them. Correction: Obtain documentation of a current, Department approved, signed Standard Precautions training for the staff members listed above. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.130.A · During hours of operation, a facility must allow access to parents and guardians having legal custody of a child in care to those areas of the facility that are licensed for child care.

It was identified through a discussion with staff that parents/guardians are not allowed in the building to pick-up/drop-off their children due to school security measures. Correction: During hours of operation, a licensed child care facility must allow access to parents/guardians to the areas of the facility that are licensed for child care. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: ratio. 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 8 staff files and observed all 8 staff members to be missing documentation of training in fire safety and the use of available fire extinguishers and fire alarms. Correction: Obtain documentation of training in fire safety and the use of available fire extinguishers and fire alarms for the staff members missing it. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Identified the program did not have documentation of emergency drills for the past 12 months available for review. Correction: All drills must be held in accordance with rule and documented. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.512.C.6 · Staff designated by the program director to give medications must complete the Department-approved medication administration training and have current annual delegation or more often as determined by the Child Care Health Consultant. Delegation must be from the center’s Current Child Care Health Consultant who must observe and document the competency of each staff member involved in medication administration. All staff administering medication must have current Department-approved Cardiopulmonary Resuscitation (CPR), first aid training prior to administering medication with the following exceptions:

Reviewed 8 staff files and did not observe any of the staff members to have current annual medication administration delegation. Correction: Obtain current annual medication administration delegation for the staff members delegated to give medications. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: ratio. Marked corrected in the state record.

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

There were several instances during the two hour inspection where children were not being directly supervised by school-age child care staff, such as children going down the hall to get drinks by themselves, children being let into the building from the playground and the back door being closed while no staff members were in the cafeteria. Correction: At all times, school-age child care personnel must be directly supervising the children. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: supervision. Marked corrected in the state record.

2.127.C · At all times during the operating hours of a family child care home, child care center, preschool, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ school-age child care center, children’s resident camp and Neighborhood Youth Organization, the facility must post in a prominent and conspicuous location information regarding the procedures for filing a complaint with the Colorado Department of Early Childhood, including the telephone number and mailing address.

Observed the facility to not have not posted the information regarding the procedure for filing a complaint with the Colorado Department of Early Childhood in a prominent and conspicuous location. Correction: Post the information regarding the procedure for filing a complaint with the Colorado Department of Early Childhood in a prominent and conspicuous location. Correct immediately by 8/29/24. Corrected at the time of visit by the Director posting it on the bulletin board by the door. No written response is required. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Marked corrected in the state record.

2.127.D · All facilities, except family child care homes must post in every room of the child care facility, excluding bedrooms and living areas, the license capacity of the room and the staff-to-child ratio required by regulation to be maintained for the age of children cared for in the room.

Observed the facility to be missing ratios and capacities postings. Correction: Post ratios and capacities in every licensed room. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: ratio. 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 8 staff files and observed 4 staff members (Ashley Packard, Anna Johnson, Anastasia Ader and Kammie Henderson) to be missing documentation of 15 hours of ongoing training. Correction: Obtain documentation of 15 hours of annual training for the staff members listed above. Correct and submit written statement of compliance with overall response by 9/29/24. Correct by 09/29/2024

Corrected Corrected by Sep 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.506.I · A written policy regarding visitors to the center must be posted and a record maintained daily by the center that includes, at a minimum, the visitor's name and address and the purpose of the visit. At least one piece of photo identification must be inspected for individuals who are strangers to personnel at the center.

Observed the facility to be missing a visitor's record. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: A record of daily visitor's must be maintained by the facility that includes the visitor's name, address and purpose of visit. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 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 8 staff files and observed 4 staff members (Anna Johnson, Rian Owens, Anastacia Ader, Charlotte Granrud) to be missing documentation of a First Aid/CPR module training. Correction: Obtain documentation of a First Aid/CPR module training or First Aid/CPR certification, for the staff members listed above. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 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 8 staff files and observed all 3 staff members (Charlotte Granrud, Rian Owens, Anastacia Ader) to be missing documentation of a current, Department approved Mandated Reporter training. Correction: Obtain documentation of a Department approved Mandated Reporter training for the staff missing it. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. 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 8 staff files and observed 2 staff members (Rian Owens and Charlotte Granrud) to be missing documentation of a Department approved Emergency and Disaster Prep training. Correction: Obtain documentation of a Department approved Emergency and Disaster Prep training for the staff members missing it. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 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 8 staff files and observed 1 staff member, Rian Owens, to be a Program Lead and to be missing documentation of a Department approved Playground Safety for School-Aged Child Care Centers training. Correction: Obtain documentation of a Department approved Playground Safety for School-Aged Child Care Centers training, for the staff member listed above. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. Marked corrected in the state record.

2.508.B.1 · 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 injury prevention; FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 8 staff files and observed 1 staff member, Rian Owens, to be a Program Lead and to be missing documentation of a Department approved Injury Prevention training. Correction: Obtain documentation of a Department approved Injury Prevention training, for the staff member listed above. Correct immediately by 8/29/24 and submit written statement of compliance with overall response by 9/29/24. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: recordkeeping. 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 8 staff files and observed 2 staff members (Isiah Broce and and Charlotte Granrud) to be missing documentation of a Trails Child Abuse and Neglect background check 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 Isiah Broce and and Charlotte Granrud have reviewed the powerpoint within 24 hours. Submit documentation of TRAILS background check clearance Letters for staff members Isiah Broce and and Charlotte Granrud with written response to the Specialist. Correct by 08/29/2024

Corrected Corrected by Aug 29, 2024

Category: supervision. Marked corrected in the state record.