Inspire PRS @ Johnstown Community YMCA

2.213.G · Within thirty (30) calendar days of employment, all employees and regular volunteers must be trained using 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 known child abuse or neglect. This training must be renewed annually.

Reviewed 13 staff files and observed 2 staff to have an expired Mandated Reporter training. Correction: Obtain a current, Department Approved Mandated Reporter training for the staff members whose has expired. Correct immediately by 11/4/2025 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.121.J.1 · The following background check requests must be submitted and successfully completed for each state an individual has resided in, in the past five years, 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 13 staff files and observed 1 staff to be missing documentation of an Out-of-state clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's

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2.213.F · 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 the Department-approved Introduction to First Aid and CPR module. The module must be renewed every two (2) years.

Reviewed 13 staff files and observed 2 staff to have an expired First Aid/CPR module training Correction: Obtain a current, Department Approved CPR First Aid training or the modulefor the staff members whose has expired. Correct immediately by 11/4/2025 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.213.N · Within thirty (30) calendar days of employment and annually, all staff responsible for the collection, review, and maintenance of the child immunizations records must complete the Colorado Department of Public Health and Environment immunization course.

Reviewed 13 staff files and observed the staff member responsible for the children's immunizatin records to have an expired CDPHE Immunization training. Correction: Obtain a current, Department Approved Immunization training for the staff members whose has expired. Correct immediately by 11/4/2025 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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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), FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 13 staff files and observed 1 staff to be missing documentation of a trails child abuse and neglect clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that the staff member has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letter for staff member with written response to the Specialist. Correct by 11/04/2025

Corrected by Nov 4, 2025

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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 13 staff files and observed 3 staff to be missing documentation of a CBI clearance letter and 2 staff to be missing documentation of an FBI clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that the staff members have reviewed the powerpoint within 24 hours. Submit documentation of CBI and FBI Clearance Letter for staff members with written response to the Specialist. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 13 staff files and observed 1 staff to have an expired Standard Precautions training. Correction: Obtain a current, Department Approved Standard Precautions training for the staff member whose has expired. Correct immediately by 11/4/2025 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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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 obseved the facility to have not documented a tornado drill in March 2025 and only documented two (8/11/25 and 9/16/25) emergency drills (lockdown and active shooter on premises drill) for the year. Correction: Drills must be held in accordance with rule and documented. Correct immediately by 11/4/2025 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

Broken crayon pieces that fit in a choke tube in the Sloth's classroom (2.5- 3 year olds), which poses a potential choking hazard. Correction: Toys, toy parts, equipment and any material accessible to children under 3 years of age must not be a choke hazard. Correct immediately by 11/4/2025. Corrected at the time of visit by the Director making them inaccessible to the children. No written response is required. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.220.J · If a medication is out of date or left over, the parent(s)/guardian(s) is responsible for picking up the medication. If the parent(s)/guardian(s) do not respond, the center must dispose of the medications as required by the FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Colorado Department of Public Health and Environment.

expired medications in the Sloth and Tocan classroom Correction: If a medication is out of date or left over it must be disposed of according to rule. Correct immediately by 11/4/25 and submit written statement of compliance with overall response by 11/11/25. Correct by 11/04/2025

Corrected by Nov 4, 2025

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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:

An individual health care plan in the Toucan's classroom was expired. Correction: The plan must be updated annually. Correct immediately by 11/4/25 and submit written statement of compliance with overall response by 11/11/25 Correct by 11/04/2025

Corrected by Nov 4, 2025

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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 13 staff files and observed 1 staff to be missing documentation of a Trails clearance letter within 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 the staff member has reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letter for staff member with written response to the Specialist. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.121.D.5 · Every five (5) years, requests for FBI criminal record checks must be renewed by completing the FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 13 staff files and observed 1 staff to be missing documentation of a FBI clearance letter within 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 the staff member has reviewed the powerpoint within 24 hours. Submit documentation of FBI Clearance Letter for staff member with written response to the Specialist. Correct by 11/04/2025

Corrected by Nov 4, 2025

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2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 7 staff files and observed 4 staff members (Kathy W, Madeline C, Kelly S, Desiree V) to have expired Standard Precautions trainings. Correction: Obtain documentation of a current, Department approved Standard Precautions training for the staff members listed above. Correct immediately by 12/3/24 and submit written statement of compliance with overall response by 1/3/25. Correct by 12/03/2024

Corrected by Dec 3, 2024

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2.213.G · Within thirty (30) calendar days of employment, all employees and regular volunteers must be trained using 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 known child abuse or neglect. This training must be renewed annually.

Reviewed 7 staff files and observed 2 staff members (Kathy W, and Kelly S) to have expired Mandated Reporter trainings. Correction: Obtain documentation of a current, Department approved Mandated Reporter training for the staff members

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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 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 7 staff files and observed 2 staff members (Jenna W (DOH 7/11/24) and Madeline C DOH 2/10/24) to be missing a health statement within 30 days of hire. Correction: Obtain a current health statement for the staff members listed above and maintain in their file. Correct and submit written statement of compliance with overall response by 1/3/2025. Correct by 01/03/2025

Corrected by Jan 3, 2025

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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.

Observed the facility's health inspection to be expired (11/2/2024). Correction: Obtain documentation of a current health inspection. Correct immediately by 12/3/24 and submit written statement of compliance with overall response by 1/3/2025. Correct by 12/03/2024

Corrected by Dec 3, 2024

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2.138.A · Emergency drills, lockdown and active shooter on premises drills must be held at least quarterly but FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 2024 drill log and observed no fire drills were conducted in Feb, March, July, August, or November. No tornado drills were held in March, June and October. No emergency drills were held at all in 2024. Correction: All drills must be held in accordance with rule. Correct immediately by 12/3/24 and submit written statement of compliance with overall response by 1/3/2025. Correct by 12/03/2024

Corrected by Dec 3, 2024

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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 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 3 children to have expired health statements. Correction: Obtain a current health statement for all children in care. Correct and submit written statement of compliance with overall response by 1/3/25. Correct by 01/03/2025

Corrected by Jan 3, 2025

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

Observed a cord plugged into an outlet and not plugged into a device, accessible to children in the Toucan's room, which poses a potential safety hazard. Correction: Indoor and outdoor equipment, materials and furnishings must be sturdy, safe and free from hazards. Correct immediately by 12/3/24. Corrected at the time of visit by the Director removing the cord from the outlet. No written

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2.126.B · Pursuant to section 19-3-304, C.R.S., any caregiver or staff member in a child care facility who has reasonable cause to know or suspect that a child has been subjected to abuse or neglect or who has observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect shall immediately upon receiving such information report or cause a report to be made of such fact to the county department of human or social services, the local law enforcement agency, or through the child abuse hotline reporting system as set forth in section 26-5-111, C.R.S.

Identified that SM1 did not immediately upon receiving information, report an allegation of abuse. Correction: Staff must report allegations of abuse immediately upon receiving that information. Correct immediately by 4/20/24 and submit written statement of compliance with overall response by 5/7/24. Correct by 04/30/2024

Corrected by Apr 30, 2024

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2.126.D.3 · An agency or facility must not interview staff or children regarding the specific allegation(s) of child abuse or child neglect until the county department of human or social services and/or local law enforcement agency has had the opportunity to interview all appropriate individuals and completed their investigation.

Identified that SM1 interviewed SM2, prior to hearing whether the County accepted the assessment for investigation or not. Correction: Staff must not interview staff regarding specific allegations of child abuse until the county has had the opportunity to interview staff.. Correct immediately by 4/20/24 and submit written statement of compliance with overall response by 5/7/24. Correct by 04/30/2024 ________________________________________________ ________________________________________________

Corrected by Apr 30, 2024

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2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

A sensory bottle in the Sloth room, had a loose cap, and small beads inside and was accessible to children under the age of 3 years. Correction: Toys, toy parts, furnishings, equipment, and any other materials accessible to children under three years of age, must not be a choke hazard. Correct immediately by 4/19/24. **Corrected at the time of visit by the Director throwing

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2.229.H · Sharp tools and instruments must be stored in areas inaccessible to children.

Observed two pairs of sharp adult scissors on a shelf in the Toucans room accessible to children. Correction: All sharp tools must be kept out of the reach of children at all times. Correct immediately 1/19/2024. Corrected at the time of visit by the teacher putting the scissors in an area inaccessible to children. No written response is

Corrected by Jan 19, 2024

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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.

Observed a power strip with an uncovered outlet on a shelf accessible to children in the Toucan room and Jaguar room. Correction: All electrical outlets accessible to children must be covered at all times. Correct immediately 1/19/2024. Corrected at the time of visit by the teachers putting covers on the outlets. No written response is required. Correct by 01/19/2024

Corrected by Jan 19, 2024

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2.213.F · 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 the Department-approved Introduction to First Aid and CPR module. The module must be renewed every two (2) years.

Reviewed 6 staff files and observed 1 staff member, K Samborski (DOH 9/2021) to be missing documentation of a current Department approved CPR and First Aid Module or certification. Correction: Obtain documentation of a current Department approved PDIS CPR and First Aid module training for the staff member listed above. Correct immediately by 1/19/24 and submit a written statement of compliance with overall response by 2/19/2024. Correct by 01/19/2024

Corrected by Jan 19, 2024

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2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 6 staff files and observed 1 staff member, H Willis DOH 1/2029) to have expired (6/5/2023) Standard Precautions trainings. Correction: Obtain documentation of a current Department approved Standard Precautions training for the staff members

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2.121.J.1 · The following background check requests must be submitted and successfully completed for each state an individual has resided in, in the past five years, 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 6 staff files and observed 1 staff member, C Garcia, to not have documentation of an out-of-state 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 C Garcia has reviewed the powerpoint within 24 hours. Submit documentation of Out of State Clearance Letters for staff members C Garcia with written response to Specialist.

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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 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 medical statement. Correction: Obtain current medical statements for all children in care. Correct and submit written statement of compliance with overall response by 2/19/24. Correct by 02/19/2024

Corrected by Feb 19, 2024

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2.229.C · Items labeled “keep out of reach of children” must be inaccessible to children.

Observed 2 cans of shaving cream labeled "keep out of reach of children" in an unlocked drawer in the Toucan room. Correction: All items labeled "keep out of reach of children" must be kept out of the reach of children at all times. Correct immediately 1/19/2024. Corrected at the time of visit by the teacher locked the drawer. No written response is required. Correct by 01/19/2024

Corrected by Jan 19, 2024

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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.

Reveiwed the drill log for the facility and no fire drills were documented in November and December of 2023 and only 2 emergency drills were documented in 2023 (March 2, 2023 and July 3, 2023). Correction: All drills must be held in accordance with rule. Correct immediately by 1/19/24 and submit a written statement of compliance with overall response by 2/19/24. Correct by 01/19/2024

Corrected by Jan 19, 2024

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