7.701.34.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.

During the safety walk-through, it was observed that the fire department inspection report was missing. Correction: Immediately ensure that there is a current fire department inspection report posted and updated every 2 years. Submit a copy of the fire department inspection report and a written statement of compliance by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

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

7.712.42.D.5 · . All Child Care Health Consultants (CCHC) must show evidence they have completed the Colorado Department of Public Health and Environment (CDPHE) immunization course annually.

While reviewing the nurse's files noticed that the Colorado Department of Public Health and Environment immunization course had expired on 2/8/2021. Correction: Immediately ensure that the nurse completes the CDPHE immunization course every year. Submit a copy of the training certificate and a written statement of compliance by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

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

7.701.33.J.1.a.b.c · 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-aged child care facilities, family child care homes, and qualified exempt provider homes: a. State criminal history check b. State sex offender registry check c. State abuse and neglect registry check

While reviewing 2 staff files, found 1 staff file (Nathan) was missing their Out of State Clearance letter and was working alone with children. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage PowerPoint. Submit verification that Nathan G. have reviewed the PowerPoint within 24 hours, 10/17/2023. Submit documentation of Out of State Clearance Letters for Nathan G with written response to Specialist by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

Category: supervision. 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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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.

During a safety walk-through of the facility reviewed the emergency drill log and noticed that the Fire Drill was not completed in August 2023. the tornado drill was not completed in August or September, and there were no emergency drills (lockdown, evacuation, or active shooter on-premise) completed. Correction: Immediately ensure fire drills are completed monthly, tornado drills are completed from March to October monthly, and all other drills are completed quarterly. Submit a plan of when all drills will be completed for the next year and submit a written statement of compliance by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.D.3 · . The center must maintain documentation including the child care health consultant’s (CCHC) Department of Regulatory Agencies (DORA) proof of RN or MD current licensure in good standing, a brief biography highlighting applicable knowledge, experience and approximate dates worked as a school nurse or Child Care health Consultant commenced.

While reviewing the nurse's file, noticed that the nurses' license was missing. Correction: Immediately ensure that there is a current copy of the nurses' license available. Submit a copy of the license and a written statement of compliance by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

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

7.712.42.C.1 · Program aides must be at least sixteen (16) years of age. Program aides must work directly under the supervision of the program director or program leaders and must never be left alone with children.

While in the cafeteria observed the aide (Nathan) left alone with the children while the director answered the front door. Correction: Immediately ensure that Program aides are under the direct supervision of the program director or program leaders, and are never left alone with the children. Submit a written statement of compliance by 10/23/2023. Correct by 10/16/2023

Corrected Corrected by Oct 16, 2023

Category: supervision. Marked corrected in the state record.