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.

Reviewed the facility's drill log and observed them to have not completed any emergency drills, lock down and active shooter on premises drills, this school year. Correction: All drills must be held in accordance with rule. Correct immediately by 12/4/24 and submit written statement of compliance with overall response by 1/4/2025. Correct by 12/04/2024

Corrected Corrected by Dec 4, 2024

Category: recordkeeping. Marked corrected in the state record.

2.219.B.2 · Within thirty (30) calendar days of admission, and within thirty (30) calendar days following the expiration date of a previous health statement, the parent(s)/guardian(s) of each child must submit a statement of the FAX 303-866-4453 Phone 303-866-5948 N_a_m_e _: O_U_R_ S_AV_IO_R_S_ L_UT_H_E_RA_N_ E_A_RL_Y_ C_H_ILD_H_O_O_D_ C_TLiRc_e_ns_e _Nu_m_b_er _: 4_7_38_7_______ ________________________________________________ child’s current health status or written verification of a scheduled appointment with a health care provider. The statement of the child’s current health status must be signed and dated by a health care provider who has seen the child within the last twelve (12) months, or within the last six (6) months for children less than two and one-half (2½) years of age. The statement must include when the next visit is required by the health care provider. All health statements must be kept at the center.

Reviewed a random sampling of 6 children's files and observed one child to have an expired health statement. Correction: Obtain a current health statement for all children whose have expired. Correct and submit written statement of compliance with overall response by 1/4/2025. Correct by 01/04/2025

Corrected Corrected by Jan 4, 2025

Category: ratio. Marked corrected in the state record.

2.218.C.5 · The individual health care plan must be updated at least every twelve (12) months from the date of the initial plan and as changes occur. The plan must include all information needed to care for the child, must be signed by the health care provider, parent(s)/guardian(s) and must include, but not be limited to, the following:

Observed a child's health care plan to not be signed by the health care provider. Correction: Obtain the health care provider's signature on the child's health care plan. Correct immediately by 12/4/2024 and submit written statement of compliance with overall response by 1/4/2025. Correct by 12/04/2024

Corrected Corrected by Dec 4, 2024

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

2.220.D · Over-the-counter medication must be kept in the originally labeled container and be labeled with the child's first and last name.

Observed an over-the-counter medication to not be labeled with the child's first and last name. Correction: Over-the-counter medication must be kept in the originally labeled container and be labeled with the child's first and last name. Correct immediately by 12/4/24. Corrected at the time of visit by the Director writing the child's name on the medication. No written response is required. Correct by 12/04/2024

Corrected Corrected by Dec 4, 2024

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

2.121.D.4.a · Criminal background check requests must be successfully completed prior to an individual caring FAX 303-866-4453 Phone 303-866-5948 N_a_m_e _: O_U_R_ S_AV_IO_R_S_ L_UT_H_E_RA_N_ E_A_RL_Y_ C_H_ILD_H_O_O_D_ C_TLiRc_e_ns_e _Nu_m_b_er _: 4_7_38_7_______ ________________________________________________ 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 5 staff files and observed 2 staff members (Brianna O and Diana M) to be missing documentation of a CBI 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 Brianna O and Diana M has reviewed the powerpoint within 24 hours. Submit documentation of CBI Clearance Letters) for staff members Brianna O and Diana M with written response to the Specialist. Correct by 12/04/2024

Corrected Corrected by Dec 4, 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.

Reviewed 5 staff files and observed 1 staff member (Heather P) to be missing documentation of a Trails letter (dated 4/21/2014) in the last 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 member Heather P has reviewed the powerpoint within 24 hours. Submit documentation of Trails Clearance Letter for staff member Heather P with written response to the Specialist. Correct by 12/04/2024

Corrected Corrected by Dec 4, 2024

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

2.213.H · Within ninety (90) calendar days of employment, all staff required to register with the Colorado Shines Professional Development Information System (listed in rule section 2.208(D)) must complete the Department-approved training course: Introduction to the Early Intervention and Preschool Special Education Programs. This course is required once and will be counted towards ongoing professional development.

Reviewed 4 staff files and observed 1 file, Brianna O., missing documentation of Introduction to early intervention and preschool special education training. Correction: Obtain documentation of Introduction to early intervention and preschool special education training. Correct by 02/23/2024

Corrected Corrected by Feb 23, 2024

Category: recordkeeping. Marked corrected in the state record.