2.120.C.1.a.1 · 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: Individuals who have obtained a successfully completed CBI or FBI record check may care for children, for no longer than ninety (90) calendar days, while waiting for all other required background checks to be completed. The individual must be supervised at all times by an individual who has successfully completed all required background checks.

reviewed 7 staff files and observed Deana K DOH 12/2024 and Lisa C DOH 12/2024 and Lisa S DOH 8/2024 to have no documentation of TRAILS clearance letter. Observed Deana and Lisa C to be working directly with children at time of visit and not working directly under the supervision of a staff member that has all clearance background checks. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letters for staff members with written response to the Specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: supervision. Marked corrected in the state record.

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.

in Katies classroom by the train table and electrical outlet with no protective cover to be accessible to children. Correction: In room used by children all electrical outlets accessible to children must have protective covers or safety outlet must be installed correct immediately and send written response to specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Marked corrected in the state record.

2.213.D · Staff working with children less than three (3) years of age must complete a Department-approved prevention of shaken baby/abusive head trauma training prior to working with children less than three (3) years of age. This training must be renewed every two (2) years and will be counted towards ongoing professional development.

reviewed 7 staff files and observed Lisa C. to be missing documentation of department approved Shaken baby head trauma training. Lisa C DOH 12/2024. Lisa to be working directly with children day of visit. Correction: Obtain current department approved shaken baby head trauma training for staff and add to staff file correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: recordkeeping. Marked corrected in the state record.

2.121.D.5 · Every five (5) years, requests for FBI criminal record checks must be renewed by completing the 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 7 staff files and observed Traci A to need to renew FBI clearance letter as of 2/11/2025. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of FBI Clearance Letters for staff members with written response to the Specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

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

2.131.A.1 · Every application used in the State of Colorado for employment with a child care provider or facility, or for the certification of a foster home, must include the following notice to the applicant: “Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished accordingly.”

reviewed 7 staff files and observed Lisa C and Lisa S to be missing signed perjury statement. Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obntain current Perjury statement for both staff and add to staff file and send written verification to specialist with response. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

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 7 staff files and observed Lisa C and Lisa S to be missing documentation of disaster emergency training Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obtain current department approved emergency disaster preparedness training for all staff and add to staff file. Correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: recordkeeping. 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 7 staff files and observed Lisa C and Lisa S to be missing documentation of fire extinguisher and fire alarm safety training for Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obtain current documentation of fire extinguisher and fire alarm safety training for Staff and add to staff file. Correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 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 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 drill log and notice that fire had not be held since September and tornado was only held in September as well. Correction: Fire drills must be held monthly, Tornado drills must be held monthly from March- October and a record of all

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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 Erin H to be missing self- reporting signed health statement and Lisa C and Lisa S to be missing medical health statements. Lisa C DOH 12/2024 and Lisa S DOH 8/2024 Correction: All staff must submit medical health statements and add to staff files and send written verification to specialist with response. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

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

2.212.J · Prior to working with children, each staff member must read and be instructed about all policies and procedures of the center. Staff members must sign a statement indicating that they have read and understand the center's policies and procedures.

reviewed 7 staff files and observed Lisa C and Lisa S to be missing documentation of reading all policies and procedures of the center for Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obtain missing documentation of staff having read all policies and procedures of the center, correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Marked corrected in the state record.

2.212.K · Within thirty (30) calendar days of employment at the center, each staff member must read and be instructed about all licensing rules governing child care centers. Staff members must sign a statement indicating that they FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ have read and understand the licensing rules.

reviewed 7 staff files and observed Lisa C and Lisa S to be missing documentation of reading all licensing rules governing the center for Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obtain missing documentation of staff having read all licensing rules governing the center, send written verification to specialist with response. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Marked corrected in the state record.

2.212.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 7 staff files and observed Lisa C and Lisa S to be missing documentation of reading all policies and procedures for the administration of medications for the center for Lisa S DOH is 8/2024 and Lisa C DOH 12/2024. Correction: Obtain missing documentation of staff having read policies and procedures for the administration of medications for the center and correct immediately send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: ratio. Marked corrected in the state record.

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 lisa C and Lisa S to be missing documentation of standard precautions training Lisa S DOH is 8/2024 and Lisa C DOH 12/2024.Observed Traci to have expired Standard precautions training as of 3.11.2025. Correction: Obtain current standard precautions training for all staff and add to staff file. Correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

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, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 7 staff files and observed Deana K DOH 12/2024 and Lisa C DOH 12/2024 and Lisa S DOH 8/2024 to have no documentation of TRAILS clearance letter. Observed Deana and Lisa C to be working directly with children at time of visit. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of TRAILS Clearance Letters for staff members with written response to the Specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: supervision. Marked corrected in the state record.

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 7 staff files and observed Traci A to have expired 1st aid CPR and to be missing module training as of 2.2025. Observed Lisa C to have no documentation of 1st aid CPR module training. Lisa C DOH is 12/2024. Correction: Obtain current 1st aid CPR module training for staff and add to staff file. Correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: recordkeeping. Marked corrected in the state record.

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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

reviewed 7 staff files and observed Traci A to have expired child abuse prevention and reporting training as of 3.11.25. Observed Lisa C and Erin H to have no documentation of child abuse prevention and reporting training. Lisa C DOH 12/2024.Erin H DOH 8/2023. Correction: Obtain current department approved child abuse prevention and reporting training for all staff and add to staff file. Correct immediately and send written verification to specialist with response. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Category: recordkeeping. 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 7 staff files and observed Lisa C to have no documentation of Intro to Early Intervention preschool training. Lisa C DOH 12/2024. Correction: Obtain current documentation of Intro to Early Intervention and preschool special education programs for staff and add to file and send written verification to specialist with response. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Category: recordkeeping. Marked corrected in the state record.

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 7 staff files and observed Lisa C to have no documentation of Recognizing the impact of bias on early childhood professionals training. Lisa C DOH 12/2024. Correction: Obtain current documentation of Rocognizing the impact of bias on early childhood professionals training for staff and add to file and send written verification to specialist with response. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Category: recordkeeping. Marked corrected in the state record.

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

fellowship hall a cabinet under a sink to have cascade and stove cleaner to be labeled "Keep out of reach of children" to be accessible to children. Correction: Make all Items labeled "keep out of reach of children" inaccessible to children correct immediately and send

Open Not marked corrected in the state record

Open / not marked corrected.

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

unlocked cabinet drawer in fellowship hall with sharp knives to be accessible to children. Correction: Make all sharp tools /instruments inaccessible to children correct immediately and send written response to specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

Marked corrected in the state record.

2.230.C.1.a · All climbing equipment eighteen (18) inches or higher must have resilient surfacing of at least six (6) inches in the use zone surrounding the equipment.

in playground gray castle with blue slide to be on resilient surface of no more than 3 inches of resilient depth. Correction: All climbing equipment must have resilient surfacing of at least 6 inches, correct immediately and send written response to specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

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

2.209.A.7 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include: A dated, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ written authorization for emergency medical care signed and updated annually by the parent(s)/guardian(s). The authorization must be notarized if required by the local hospital, clinic, or emergency health care facility;

reviewed 4 children files and observed Ch1 and Ch2 to have expired emergency health statements as of 10/12/2024 and 12/13/2024. Correction: Obtain current emergency health statements for all children and add to file. Correct immediately and send written response to specialist. Correct by 03/24/2025

Corrected Corrected by Mar 24, 2025

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

2.206.A · At the time of enrollment, and upon amendments to policies and procedures, the center must give the parent(s)/guardian(s) the center’s policies and procedures and provide the opportunity to ask questions. Written copies must be available either electronically or in hard copy. The center must obtain a signed document stating that the parent(s)/guardian(s) have received the policies and procedures, and by signing the policies and procedures document, the parent(s)/guardian(s) agree to follow, accept the conditions of, and give authorization and approval for the activities described in the policies and procedures.

reviewed 4 children files no documentation of parents receving the policies and procedures from the center. Correction: At enrollment parents must be given the policies and procedures of the center and added to children files and send written response to specialist. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Marked corrected in the state record.

2.209.A.8 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include:Written authorization, obtained in advance of the event from a parent/guardian, for a child to participate in field trips or special activities, whether scheduled or unscheduled, whether walking or riding in an approved vehicle;

reviewed 4 children files and observed all to be missing written authorization for field trips and transportation. Correction: Child records must be update annually and must have written authorization of field trips and transportation correct and add to children files and send written response to specialist. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Category: transportation. Marked corrected in the state record.

2.220.K · Topical preparations such as petroleum jelly, diaper rash ointments, sunscreen, insect repellent, and other ointments may be administered to children with written authorization from the parent(s)/guardian(s). These preparations may not be applied to open wounds or broken skin unless there is a written order by the prescribing health care provider.

reviewed 4 children files and observed all of them to be missing written authorization for topical preparations. Correction: Obtain written authorization for all children for topical preparations and add to children files and send written response to specialist. Correct by 04/24/2025

Corrected Corrected by Apr 24, 2025

Category: ratio. Marked corrected in the state record.

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 4 staff files and observed Traci to have expired medical health statement as of 3/2024. Correction: Obtain current health statement for staff and add to staff file and send written to specialist with response. Correct by 05/24/2024

Corrected Corrected by May 24, 2024

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

2.209.A.7 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include: A dated, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ written authorization for emergency medical care signed and updated annually by the parent(s)/guardian(s). The authorization must be notarized if required by the local hospital, clinic, or emergency health care facility;

reviewed 3 children files and observed ch1 to have expired emergency medical authorization as of 1/12/23. Correction: Obtain current emergency medical authorization for Ch1 and add to child's file. Correct immediately and send written verification to specialist with response. Correct by 04/26/2024

Corrected Corrected by Apr 26, 2024

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

2.219.B.1 · At the time of admission, the parent(s)/guardian(s) must provide for each child entering the center: Documentation of school-required immunization status or certificate of medical or nonmedical exemption, is required by the Colorado Board of Health. Up-to-date school-required immunizations must be documented as specified on the Colorado Department of Public Health and Environment certificate of immunization or on an “approved alternate” Certificate of Immunization, defined in Colorado Department of Public Health and Environment rules located in 6 CCR 1009-2 rule section VI(A), (May 15, 2023), no later editions or amendments are incorporated. These regulations are available from the Colorado Department of Public Health and Environment at no cost at www.sos.state.co.us/CCR. These regulations are also available for public inspection and copying at the Colorado Department of Early Childhood, 710 S. Ash St., Bldg. C, Denver, CO 80246, during regular business hours. Colorado law requires proof of immunization status or exemption be provided prior to or on the first day of admission.

reviewed 3 children files and observed ch3 to have immunization on non- approved form. Correction: Obtain current child immunizations on state approved form and add to child's file and send written verification to specialist with response. Correct by 05/24/2024

Corrected Corrected by May 24, 2024

Category: health medication. 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 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ statement must include when the next visit is required by the health care provider. All health statements must be kept at the center.

reviewed 3 children files and observed ch3 to have no documenation of medical health statement. Correction: Obtain current medical health statement for child and add to child's file and send written verification to specialist with response. Correct by 05/24/2024

Corrected Corrected by May 24, 2024

Category: ratio. Marked corrected in the state record.