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, 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;

At the time of the visit, reviewed 4 children's files and observed 4 files to be lacking documentation of emergency medical authorization. Correction: Immediately ( 8/27/2025), review all children's files. Each child must have documentation of emergency medical authorization. Submit a written statement of compliance by 9/3/2025. Correct by 08/27/2025

Corrected Corrected by Aug 27, 2025

Category: health medication. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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;

At the time of the visit, reviewed 4 children's files and observed 4 files to be lacking documentation of field trip authorization. Correction: Immediately ( 8/27/2025) review all children's files. All files must have documentation of field trip authorization. Submit a written statement of compliance by 9/3/2025. Correct by 08/27/2025

Corrected Corrected by Aug 27, 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.

At the time of the visit, reviewed 4 children's files and observed 4 files to be lacking documentation of topical authorization. Correction: Immediately ( 8/27/2025), review all children's files. All files must include documentation of topical authorization. Submit a written statement of compliance by 9/3/2025. Correct by 08/27/2025

Corrected Corrected by Aug 27, 2025

Category: ratio. 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.

At the time of the visit, reviewed 4 children's files and observed 4 files to be lacking documentation that parents received the facilities policies and procedures. Correction: Immediately ( 8/27/2025), review all children's files. All files must include documentation that parents received the facilities policies and procedures.

Open Not marked corrected in the state record

Open / not marked corrected.

2.229.U · An appropriate supply of play materials must be readily accessible to children and must be arranged in an orderly manner so that children can select, remove, and replace the play materials either independently or with minimum assistance.

At the time of the visit, in the Saints classroom, two shelves containing play materials were turned toward each other, where the children could not play with those items. Correction: Immediately ( 8/27/2025), play materials must be readily assessible to children and must be arranged in a way that children can select, remove and replace the materials independently. **Corrected at the time of the visit when the teacher made the shelves of materials accessible to children. Submit a written statement of future compliance by 9/3/2025. Correct by 08/27/2025

Corrected Corrected by Aug 27, 2025

Marked corrected in the state record.

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

In the W008 classroom and Youth Room, chairs were stacked 4-5 high, causing a potential hazard. Correction: Immediately, class furnishings must be safe and free of hazards. Corrected at the time of visit, the director unstacked the chairs. Submit a written statement of future compliance by 12/19/2024. Correct by 12/12/2024

Corrected Corrected by Dec 12, 2024

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

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

In the W005 classroom, Dawn dish soap labeled "keep out of reach of children" was in an unlocked cabinet under the sink, accessible to children. In the W008A classroom, hand soap labeled "keep out of reach of children" was on the sink, accessible to children. Correction: Immediately, items labeled "keep out of reach of children" must be inaccessible. Corrected at the time of visit, the director locked the cabinet and removed the hand soap. Submit a written statement of future compliance by 12/19/2024. Correct by 12/12/2024

Corrected Corrected by Dec 12, 2024

Marked corrected in the state record.

2.124.A.1.d · Within twenty-four (24) hours, excluding weekends and holidays, of the occurrence of a critical incident at the facility or within twenty-four (24) hours of a child’s return to the facility the licensee must report in writing to the Colorado Department of Early Childhood, Division of Early Learning, Licensing, and Administration the following critical incidents involving a child in the care of the facility or a staff member on duty: Any allegation of physical, sexual, or emotional abuse or neglect to a child that results in a mandatory report to law enforcement or a county department of FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ human or social services agency, or the child abuse reporting hotline as described in section 19-3-304, C.R.S.

The director at the time of the incident failed to report a critical incident to the Licensing department as required by state statute and licensing regulations within the required timeframe. Correction: Immediately, the facility must report a critical incident within the required timeframe to the Licensing department as stated in the state statute and licensing regulations. Submit a written statement of compliance by 11/6/2024. Correct by 10/30/2024 Stage II Licensing Concern : Staff member did not follow the policy regarding the facility’s name-to-face attendance tracking. - FOUNDED

Corrected Corrected by Oct 30, 2024

Category: ratio. Marked corrected in the state record.

2.206.B.7 · The written policies and procedures must be developed, implemented, and followed, and must include at a minimum the following information: 7. The procedure for identifying where children are at all times including times of transition;

Reviewed the facility's policies and procedures. Confirmed through staff statements, SM1 did not follow the facility's policies and procedures for identifying where children are at all times. Correction: Immediately, the written policies and procedures must be followed regarding the procedure for identifying where children are at all times. Submit a written statement of compliance by 11/6/2024. Correct by 10/30/2024 Stage II Licensing Concern : Teachers did not complete a name-to-face attendance tracker. - FOUNDED

Corrected Corrected by Oct 30, 2024

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 the attendance tracker and confirmed through staff statements, SM1 did not complete a name-to-face attendance verification when they arrived in the classroom. Correction: Immediately, attendance verification must be completed periodically throughout the day. Submit a written statement of compliance by 11/6/2024. Correct by 10/30/2024 Stage II Licensing Concern : A child was unsupervised in the hallway for 30 seconds. - FOUNDED

Corrected Corrected by Oct 30, 2024

Category: recordkeeping. Marked corrected in the state record.

2.223.A.1 · All children must be under the direct supervision at all times of a qualified adult who has been assigned the responsibility to supervise

Confirmed through staff statements, CH1 was unsupervised for 30 seconds. Correction: Immediately, all children must be under the direct supervision of a qualified adult at all times. Submit a written statement of compliance by 11/6/2024. Correct by 10/30/2024 Stage II Licensing Concern : CH1 was 2 years 5 months at the time of the incident and the facility is licensed for 2 years 6 months. - FOUNDED

Corrected Corrected by Oct 30, 2024

Category: supervision. Marked corrected in the state record.

2.218.A · The center must accept and care only for children of the ages for which it has been licensed. At no time shall the number of children in attendance exceed the number for which the center has been licensed.

Reviewed 2 child files. Observed CH1 age 2.5 at the time of the incident, enrolled in the facility which is licensed for children 2.6 to 16 years of age. Correction: Immediately, the center must only care for children of the ages for which it has been licensed. Submit a written statement of compliance by 11/6/2024. Correct by 10/30/2024 ________________________________________________ ________________________________________________

Corrected Corrected by Oct 30, 2024

Marked corrected in the state record.

2.229.G · Loose plastic bags must be stored in areas inaccessible to children.

In Room W008, a loose plastic bag was on the counter, accessible to children. Correction: Immediately, loose plastic bags must be stored in areas inaccessible to children. Corrected at the time of visit, the director placed the bag in a locked cabinet. Submit a written statement of future compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Marked corrected in the state record.

2.229.C · Items labeled “keep out of reach of children” must be inaccessible to children. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

In Room W005, Dawn dish soap labeled "keep out of reach of children" was in an unlocked cabinet, accessible to children. Correction: Immediately, items labeled "keep out of reach of children" must be inaccessible to children. Corrected at the time of visit, the director locked the cabinet, making the dish soap inaccessible to children. Submit a written statement of future compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Marked corrected in the state record.

2.222.A.1.b · All diaper change areas must: Have a place inaccessible to children for storing all diaper change supplies and disinfecting solutions and products;

In Room W008 and W008A, diapers were in the bathroom, accessible to children. Correction: Immediately, diaper supplies must have a place inaccessible to children, for storing. Corrected at the time of visit, the director locked the cabinet and placed the diapers in an area inaccessible to children. Submit a written statement of future compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Marked corrected in the state record.

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 Colorado Department of Public Health and Environment.

In Room W002, a child had an epi-pen, expired 5/2023. Correction: If a medication is out of date, the parent(s)/guardian(s) is responsible for picking up the medication. Submit a written statement of compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Category: health medication. 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.

On the playground, with equipment over 18", the resilient surface was less than 6". Correction: All climbing equipment 18" or higher must have a resilient surfacing of at least 6". Submit a written statement of compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Category: physical safety. 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 11 staff files. Observed Agnes W., hired 8/2023, missing documentation of an emergency and FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ disaster preparedness training. Correction: Prior to working with children, all staff must complete an emergency and disaster prepardness training. Submit documentation and a written statement of compliance by 6/14/2024. Correct by 05/14/2024

Corrected Corrected by May 14, 2024

Category: recordkeeping. 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 11 staff files. Observed Mary Ann G. and Charleen D. missing a current medical statement from a health care provider. Correction: All staff members must self-report their health histories annually. Submit a written statement of compliance by 6/14/2024. Correct by 06/14/2024

Corrected Corrected by Jun 14, 2024

Category: health medication. 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 11 staff files. Observed Tracy S., working with children less than three (3) years of age, missing current documentation of a shaken baby/abusive head trauma training. Correction: Staff working with children less than three (3) years of age must complete a Department-approved prevention of shaken baby/abusive head trauma and must renew every two (2) years. Submit documentation and a written statement

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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 11 staff files. Observed Charleen D., hired 8/2023, and Taylor O., hired 1/2023, missing current training about child abuse prevention. Correction: Within thirty (30) days of employment, all employees must complete the Department-approved training about child abuse prevention and must renew annually. Submit documentation and a written statement of compliance by 6/14/2024. Correct by 06/14/2024

Corrected Corrected by Jun 14, 2024

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 11 staff files. Observed Agnes W., hired 8/2023, missing documentation of training: Introduction to the Early Intervention and Preschool Special Education Programs. Correction: Within ninety (90) calendar days, all staff must complete the Department-approved training course: Introduction to the Early Intervention and Preschool Special Education Programs. Submit documentation and a written statement of compliance by 6/14/2024. Correct by 06/14/2024

Corrected Corrected by Jun 14, 2024

Category: recordkeeping. Marked corrected in the state record.

7.702.42.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 8 staff files. Observed Amy N-O missing documentation of a current CPR/First Aid. Correction: Within 30 days, review all staff files and all employees caring for children must complete the Department-approved Introduction to First Aid and CPR. Submit document and a written statement of compliance by 10/13/2023. Correct by 09/13/2023

Corrected Corrected by Sep 13, 2023

Marked corrected in the state record.

7.702.62.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.

In Preschool Room W002, observed 11 children and 7 children were not signed out. Correction: Immediately, staff members must complete written attendance verification periodically throughout the day.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.