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.

The program did not have documentation of a current health inspection updated since 11/21/22. Correction: Immediately, obtain documentation of a current health inspection. Submit documentation and a written statement of compliance by 9/17/25. Correct by 08/18/2025

Corrected Corrected by Aug 18, 2025

Category: health medication. 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 3 staff files. 3 staff did not have documentation of fire safety and fire extinguisher training. Correction: Immediately, obtain documentation of fire safety and the use of available fire extinguishers and fire alarms training for all staff. Submit documentation and a written statement of compliance by 9/17/25. Correct by 08/18/2025

Corrected Corrected by Aug 18, 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.

The program did not have documentation of a fire drill completed for the month of July. Correction: Immediately, complete fire drills monthly. Submit a written statement and plan of compliance by 9/17/25. Correct by 08/18/2025

Corrected Corrected by Aug 18, 2025

Category: recordkeeping. 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, 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 child files. 1 child did not have documentation of a current authorization for emergency medical care. Correction: Immediately, obtain documentation of written authorization for emergency medical care for all children annually. Submit a written statement of compliance by 9/17/25. Correct by 08/18/2025

Corrected Corrected by Aug 18, 2025

Category: health medication. 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 3 staff files. 3 staff did not have documentation of administration of medication policies and procedures training. Correction: Immediately, obtain documentation that each staff member has read and been trained on the programs policies

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

2.213.E · For every thirty (30) or fewer children in attendance, there must be at least one (1) staff member on duty who holds a current Department-approved first aid and safety certificate, including cardiopulmonary resuscitation (CPR) for all ages of children, and is responsible for administering First Aid and CPR to children. Such individuals must be with the children at all times when the center is in operation. If children are at different locations, there must be a First Aid and CPR qualified staff member at each location.

Reviewed 3 staff files. 1 staff member had an expired First Aid and CPR certification and 2 staff did not have documentation of First Aid and CPR certification from an approved vendor. There were no staff on-site with a current or approved First Aid and CPR certification. Correction: Immediately, obtain documentation of a current First Aid and CPR certification for staff from an approved vendor. Submit documentation and a written statement of compliance by 9/17/25. Correct by 08/18/2025

Corrected Corrected by Aug 18, 2025

Category: ratio. Marked corrected in the state record.

2.217.C.8 · All Department-approved child care health consultants must complete the Department- approved Colorado Department of Public Health and Environment immunization course annually. The center must obtain and maintain proof of course completion.

Reviewed the CCHC file and the file did not have documentation of a current childcare and preschool immunization training. Correction: Obtain documentation of a current child care and preschool immunization training for the CCHC. Submit documentation and a written statement of compliance by 9/17/25. Correct by 09/17/2025

Corrected Corrected by Sep 17, 2025

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

2.219.B.4 · Health statements for children over two (2) years of age to seven (7) years of age must be updated in accordance with the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care schedule for routine well child exams. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 4 child files. 1 child file did not have documentation of a current health statement. Correction: Obtain documentation of a current health statement for all children. Submit a written statement of compliance by 9/17/25. Correct by 09/17/2025

Corrected Corrected by Sep 17, 2025

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

2.206.B.12 · The written policies and procedures must be developed, implemented, and followed, and must include at a minimum the following information: The procedure for transporting children, if applicable, including transportation arrangements and parental permission for excursions and related activities

The programs preschool policies and procedures are not current and state that they do not provide transporation. The program transports preschool children for field trips. Correction: Review policies and procedures and ensure that the written policies and procedures for transporation are developed, implemented and followed. Submit documentation of updated policies and procedires with a written statement of complaince by 9/22/24. Correct by 09/22/2024

Corrected Corrected by Sep 22, 2024

Category: ratio. 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, 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 child files. 2 child files did not have documentation of a current written authorization for emergency medical care. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Immediately, review child files and ensure that the written authorization for emergency medical care is updated annually. Submit a written plan and statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

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

2.217.C.5 · For the Department-approved Child Care Health Consultant, the center must maintain documentation from the Colorado Department of Regulatory Agencies that the Registered Nurse or the Medical Doctor’s licensure is in good standing.

Michelle D, CCHC, did not have documentation of a current DORA RN license. Correction: Ensure documentation of the Colorado DORA RN license is on file for the Child Care Health Consultant. Submit documentation and a written statement of compliance by 9/22/24. Correct by 09/22/2024

Corrected Corrected by Sep 22, 2024

Category: health medication. 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 child files. 1 child file did not have written authorization for sunscreen. Correction: Immediately, review child files and ensure that each child has written authorization for sunscreen and other topical ointments. Submit a written plan and statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

Category: ratio. Marked corrected in the state record.

2.227.A.2 · The center must obtain written permission from the parent(s)/guardian(s) for any transportation of FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ their child(ren) while in care.

Reviewed 4 child files. 2 child files did not have documentation of written permission for transportation for before and after school care. Correction: Immediately, review child files and ensure that written permission is obtained from the parents/guardians for transportation of children. Submit documentation and a written statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

Category: transportation. Marked corrected in the state record.

2.230.C.1.c · Loose fill resilient surface must be raked regularly to retain its resiliency and to retain a depth of at least six (6) inches.

The wood chips under the swings and climbing rope measured one (1) inche or less and the woodchips in the use zone on the East side of the climbing structure measured four (4) to five (5) inches deep. Correction: Immediately, ensure that loose fill resilient surface is raked regularly to retain resiliency and a depth of at least six (6) inches. Submit a written plan and statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

Marked corrected in the state record.

2.217.A.9 · At least one (1) staff member with the current Department-approved medication administration training and delegation must be on duty at all times.

Reviewed 3 staff files. The facility does not have a staff member with a current delegation for medication administration. Correction: Immediately, ensure that there is at least 1 staff member on duty at all times with a Department approved medication administration training and delegation. Submit documentation and a written statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

Category: ratio. Marked corrected in the state record.

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

Reviewed 3 staff files. Jami M, Debbie W and Michael T did not have documentation of a Trails abuse and neglect request within the last 5 years. Correction: Immediately, ensure that the Trails abuse and neglect request is renewed every five (5) years. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members Jami M, Debbie W and Michael T have reviewed the powerpoint within 24 hours. Submit documentation of the Trails clearance letter for Jami M, Debbie W and Michael T with a written statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

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

2.213.L · All staff must have at least one (1) hour of child development training within ninety (90) days of employment. This training must include the major domains (cognitive, social, emotional, physical development and approaches to learning). This training is required once and will count toward ongoing training requirements if taken after the date of hire.

Reviewed 3 staff files. Michael T did not have documentation of a 1 hour child development training. Correction: Ensure all staff complete at least one (1) hour of child development training within 90 days of employment. Submit documentation and a written statement of compliance by 9/22/24. Correct by 09/22/2024

Corrected Corrected by Sep 22, 2024

Category: recordkeeping. Marked corrected in the state record.

2.214.A · Large center directors must have a current director qualifications letter issued by the Department or a current early childhood professional credential level III or higher in version 3.0 as determined by the Department prior to working as the director of a large center.

The Director, Jami M did not have documentation of a current director qualifications letter or Level III or higher 3.0 credential. Correction: Immediately, ensure that large center directors have a current director qualifications letter or early childhood professional credential 3.0 Level III or higher prior to working as a large center director. Submit documentation and a written statement of compliance by 9/22/24. Correct by 08/23/2024

Corrected Corrected by Aug 23, 2024

Marked corrected in the state record.

7.702.91.D · Volatile substances such as gasoline, kerosene, fuel oil, oil-based paints, firearms, explosives, and other hazardous items must not be stored in any area of the building used for childcare.

Pack of batteries and one loose battery in an unlocked drawer of the storage shelves near children's cubbies accessible to children posing a potential safety concern. Correction: Immediately make all hazardous items inaccessible to children. **Corrected at time of inspection - batteries were moved to a high shelf making them inaccessible to children. No response is required.** Correct by 09/27/2023

Corrected Corrected by Sep 27, 2023

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

7.702.91.H · In rooms used by children, all electrical outlets that are accessible to children must have protective covers, or safety outlets must be installed.

Two electrical outlets by the air hockey table to be missing protective covers posing a potential safety concern. Correction: Immediately install protective covers on all electrical outlets in rooms used by children. **Corrected at time of inspection - outlet covers were placed in two outlets by the air hockey table. No response is required.** Correct by 09/27/2023

Corrected Corrected by Sep 27, 2023

Marked corrected in the state record.

7.701.56.B · . At all times during the operating hours of a family child care home, child care center, school-age child care center, or children's resident camp, the facility must post its most recent licensing inspection report or a notice as to where the report may be reviewed at the facility by the parent or legal guardian of a child or their designee.

Facility to be lacking posted information of the most recent licensing inspection report or a notice as to where the report may be reviewed. Correction: At all times during the operating hours, the facility must post its most recent licensing inspection report or a notice as to where the report may be reviewed. **Corrected at time of inspection - the Director posted the appropriate information. No response is required.** Correct by 09/27/2023

Corrected Corrected by Sep 27, 2023

Marked corrected in the state record.

7.701.100.A · . Prior to caring for children, all staff must complete a State Department-approved training in emergency and disaster preparedness. 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 State Department-approved training

Reviewed 4 staff files and observed Jami to be missing documentation of emergency and disaster preparedness (or FEMA) training. Correction: Obtain and maintain documentation of emergency and disaster preparedness (or FEMA) training for all staff prior to working with children. Submit a copy of completed training with written response to specialist. Correct by 09/27/2023

Corrected Corrected by Sep 27, 2023

Category: recordkeeping. Marked corrected in the state record.