2.213.I · 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 Recognizing the Impact of Bias on Early Childhood Professionals training or other Department-approved training on implicit bias. This course is required once and will be counted towards ongoing professional development.

Reviewed 2 staff files and observed Sara G., who has been employed longer than 90 days, lacking a completed training certificate for Recognizing the Impact of Bias on Early Childhood Professionals. Correction: Provide a written statement of compliance within the overall response ensuring the program obtains documentation of training certificates for all staff, within 90 days of employment, for the Department-approved Recognizing the Impact of Bias on Early Childhood Professionals or other department approved training on implicit Bias. Correct by 08/21/2025

Corrected Corrected by Aug 21, 2025

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 program's files and observed program lacking documentation of emergency drills being conducted as required. Correction: Immediately (7/22/2025) ensure all required drills are completed within the required time frames and documentation of each drill is maintained for at least 12 months. Provide a written statement of compliance within the overall response. Correct by 07/22/2025

Corrected Corrected by Jul 22, 2025

Category: recordkeeping. Marked corrected in the state record.

2.223.A.2 · The time a child arrives and leaves the center each day must be recorded. Staff members must complete written attendance verification periodically throughout the day, including during transitions.

Reviewed program's files and observed program lacking documentation of written attendance verification being completed periodically throughout the day. Correction: Immediately (7/22/2025) ensure the program maintains documentation of written attendance verification periodically throughout the day, to include during transitions. Provide a written plan of action along with a written statement of compliance within the overall response. Correct by 07/22/2025

Corrected Corrected by Jul 22, 2025

Category: recordkeeping. Marked corrected in the state record.

2.232.A.3 · The play area must be fenced or have natural barriers, such as hedges or stationary walls at least four (4) feet high, to restrict children from unsafe areas.

The outdoor play area surrounded by wooden split rail fencing with large gaps between each wooden rail of at least 14 inches from the ground to the first rail and between all other rails is not restricting children from unsafe areas. Correction: Immediately (8/20/2024) ensure that playground fencing restricts children from unsafe areas. Provide a written statement of compliance within the overall response and submit photo documentation of updated playground fencing. Correct by 08/20/2024

Corrected Corrected by Aug 20, 2024

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 2 staff files and observed Jennifer H. lacking documentation of a completed criminal background check. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that Jennifer H. has reviewed the powerpoint within 24 hours. Submit documentation of CBI and FBI clearance letters for Jennifer H. with written response to Specialist. Correct by 08/20/2024

Corrected Corrected by Aug 20, 2024

Category: background checks. 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 2 staff files and observed Jennifer H. lacking documentation of a completed Trails background check request. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that Jennifer H. has reviewed the powerpoint within 24 hours. Submit documentation of Trails clearance letter for Jennifer H. with written response to Specialist. Correct by 08/20/2024

Corrected Corrected by Aug 20, 2024

Category: supervision. Marked corrected in the state record.

7.707.71.A.2 · Within thirty (30) days after admission, and within thirty (30) days following the expiration date, the parent or guardian 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 practitioner. The statement of the child's current health statusmust 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 under two and one-half (2-1/2 ) years of age. The statement must include when the next visit is required by the health care provider. All health statementsmust be kept at the licensed child care home.

Reviewed 8 children's files and observed 4 children to have an expired statement of current health status. Correction: Provide a written statement of compliance ensuring that within 30 days after admission and within 30 days following expiration, the program obtains a current statement of health status for each enrolled child that is signed and dated by a health care provider as indicated above, and indicates when the next visit is required. Correct by 12/15/2023

Corrected Corrected by Dec 15, 2023

Category: ratio. Marked corrected in the state record.

7.707.71.B.1 · The provider must obtain written authority to arrange for emergency medical care for each child. Written authorization to obtain emergency medical care must be on file prior to or on the first day of admission and must be re-authorized annually.

Reviewed 8 children's files and observed 7 children lacking an annually updated emergency medical authorization. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately (11/16/2023) ensure the program obtains an emergency medical authorization for each enrolled child by the first day of admission, that is re-authorized annually. Provide a written statement of compliance within the overall response. Correct by 11/16/2023

Corrected Corrected by Nov 16, 2023

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.

Reviewed program's files and observed program lacking documentation of the required fire, tornado and lockdown drills that have been completed within the last 12 months. Correction: Immediately (11/16/2023) ensure that all emergency drills, to include fire, tornado and lockdown, are conducted and documented with the above listed information. Provide a written plan of action along with a written statement of compliance within the overall response. Correct by 11/16/2023

Corrected Corrected by Nov 16, 2023

Category: recordkeeping. Marked corrected in the state record.

7.707.31.A.10 · Subsequent health evaluations for the provider and children residing in the home who are less than twelve (12) years of age must be submitted every two (2) years or as required in a written plan signed by a physician or other health professional. A new family member and/or a new resident of the home must submit to the State Department, within thirty (30) days from the date the individual began living in the home, a State Department approved FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ health evaluation form signed and dated by a licensed physician or other health professional.

Reviewed 2 staff files and observed Sara G. to have an expired health evaluation and Sandra L. lacking an approved health evaulation signed and dated by a licensed physician or other health professional. Correction: Provide a written statement of compliance within the overall response ensuring the providers and all children, less than 12 years of age residing in the home, have obtained and will maintain a current health evaluation. Correct by 12/15/2023

Corrected Corrected by Dec 15, 2023

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

7.707.32.A.4 · Prior to issuance of the license, the licensee and primary provider must complete:A State Department approved training in Standard Precautions that meets current Occupational Safety and Health Administration (OSHA) requirements prior to working with children. This training must be renewed annually and may be counted towards ongoing training requirements. This Standard Precautions training can be included as part of the Pre-Licensing training, in which case the total number of hours for Pre-licensing training required in 7.707.A1 is increased to sixteen (16) clock hours, and Standard Precautions training may count as no more than one (1) hour of the sixteen (16) clock hours; and,

Reviewed 2 staff files and observed Sara G. and Sandra S. lacking documentation of a current Department approved Standard Precautions training certificate. Correction: Immediately (11/16/2023) ensure the program obtains documentation of a current Department approved Standard Precautions training certificate for Sara G. and Sandra S. Provide a written statement of compliance within the overall response. Correct by 11/16/2023

Corrected Corrected by Nov 16, 2023

Category: ratio. Marked corrected in the state record.

7.707.32.A.9 · . Effective December 31, 2016, each provider or staff member responsible for the collection, review, and maintenance of the child immunization records must complete the Colorado Department of Public Health and Environment (CDPHE) immunization course within thirty (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 2 staff files and observed Sara G. lacking documentation of a current completed CDPHE immunization training. Correction: Immediately (11/16/2023) ensure that Sara G. obtains and maintains documentation of a current completed CDPHE immunization training. Provide a written statement of compliance within the overall response. Correct by

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

7.707.32.A.7 · Prior to issuance of the license the licensee and primary provider must complete: The State Department approved course of training for medication administration.

Reviewed 2 staff files and observed Sandra S. lacking documentation of a current completed Department approved training for medication administration. Correction: Immediately (11/16/2023) ensure that all providers, to include Sandra S., obtain and maintain documentation of a completed Department approved training for medication administration. Provide a written statement of compliance within the overall response. Correct by 11/16/2023

Corrected Corrected by Nov 16, 2023

Category: ratio. Marked corrected in the state record.

7.707.75.G · Safe Sleep Training for Family Child Care Staff All staff who work with infants must complete Department-approved safe sleep training prior to working with infants and on an annual basis.

Reviewed 2 staff files and observed Sara G. and Sandra S. to have expired Department approved safe sleep training certificates. Correction: Immediately (11/16/2023) ensure that the program obtains documentation of a current Department approved safe sleep training certificate for all staff, to include Sara G. and Sandra S. Provide a written statement of compliance within the overall response. Correct by 11/16/2023

Corrected Corrected by Nov 16, 2023

Category: physical safety. Marked corrected in the state record.

7.707.32.A.11 · . Effective December 31, 2016 each provider, staff member or regular volunteer must complete a department-approved training about child abuse prevention, including common symptoms and signs of child abuse within thirty (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 2 staff files and observed Sara G. and Sandra S. lacking documentation of a current Department approved training for child abuse prevention. Correction: Immediately (11/16/23) ensure that all staff or regular volunteers, to include Sara G. and Sandra S., complete

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.