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 9 staff files and observed Mengwe W to be missing Trails background clearance letter Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint on the CDEC website. Submit verification that staff members Mengwe W have reviewed the powerpoint within 24 hours. Submit documentation of Trails abuse and neglect clearance Letter for staff member Mengwe W with written response to Specialist. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

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

Reviewed 9 staff files and observed Joe P, Naomi B and Mary J having an expired TRAILS background clearance letters. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint on the CDEC website. Submit verification that staff members Joe P, Naomi B and Mary J have reviewed the power point within 24 hours. Submit documentation of TRAILS Clearance Letters for staff members Joe P, Naomi P and Mary J with written response to Specialist. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

Category: background checks. 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 9 staff files and observed Mary J to be having an expired FBI background clearance letter. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint on the CDEC website. Submit verification that staff members Mary J has reviewed the powerpoint within 24 hours. Submit documentation of FBI Clearance Letters for staff members Mary J with written response to Specialist. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

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

2.138.B · Drills must be held at unexpected times and under varying conditions to simulate the conditions of an actual fire or other emergency event.

Identified through Camp director, facility has not held emergency drills for camp session. Observed no documentation of drills. Correction: Drills must be held at unexpected times and under varying conditions to simulate the conditions of an actual fire or other emergency event. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

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

2.424.N · Substances which may be toxic to a child if ingested, inhaled, or handled, including, but not limited to, poisons, drugs, medicines, insecticides, herbicides, rodenticides, bleaches, chemicals, and corrosive agents must be stored in a cabinet or enclosure located in an area not used by children, stored in the original container, and properly labeled.

Chemical cleaners in closet with broken lock accessible to children in boys bathroom. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Substances which may be toxic to a child if ingested, inhaled or handled including but not limited to poisons, drugs, medicines, insecticides, herbicides, rodenticides, bleaches, chemicals and corrosive agents must be stored in a cabinet or enclosure located in an area not used by children stored in the original container and properly labeled Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

Marked corrected in the state record.

2.424.R · All areas accessible to children must be maintained in a safe condition by removal of debris, dilapidated structures, and broken or worn equipment or dangerous items.

Large wood pieces with screws under deck of the Dance Studio accessible to children causing a potential safety condition. Correction: All areas accessible to children must be maintained in a safe condition by removal of debris, dilapidated structures and broken or worn equipment or dangerous items. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

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

2.413.J.1 · Medication prescribed for campers must be from a licensed pharmacy; labeled with the name, address, and phone number of the pharmacy; name of the camper; name and strength of the medicine; directions for use; date filled; prescription number; and the name of the practitioner prescribing the medicine. When no longer needed or expired, the medication must be returned to the parent or disposed of properly.

2 over the counter standing order medications to be expired in the infirmary. Correction: When medication is no longer needed or expired, the medication must be disposed of properly. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

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

7.711.31.B · . At least ten (10) calendar days prior to admission, each camper must furnish a health history which indicates communicable diseases and chronic illnesses or injuries the individual has had, any known drug reactions and allergies, medications being taken, and any necessary health procedures or special diets.

Reviewed campers health history and observed items listed that cause known reaction. Identified through staff statement that some items listed as known to cause reactions were accessible to campers. Correction: At least 10 calendar days prior to admission, campers must furnish a health history which indicates known drug

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

7.711.22.B · . At each permanent camp there must be one health care worker who is responsible for monitoring the overall health of the campers and staff. A health care worker must be one of the following: a licensed physician, a registered nurse, a licensed practical nurse, a licensed physician's assistant, a certified nursing assistant or an individual who holds current certification in emergency medical services. All health care workers must work within their scope of practice, including the ability to work independently or with required oversight.

Identified through Director's statement that there were times during the camp season that there was not a health care worker on site 24 hours per day. Correction: At least one health care worker must be at the camp site 24 hours per day that the camp is in session. **Submit a written statement of compliance to specialist with response form by 7/ 31/ 2023 Correct by 07/24/2023 ________________________________________________

Corrected Corrected by Jul 24, 2023

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

7.711.22.D · . All staff members must complete a Department-approved Standard Precautions training prior to working with children. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 5 staff files and observed Josephine to be missing documentation of Standard Precautions training. Observed Ebany to be missing documentation of current Standard Precautions training. Correction: Obtain documentation of Department-approved Standard Precautions training and add to files **Submit a written statement of compliance to specialist with response form by 7/ 31/ 2023 Correct by 07/24/2023

Corrected Corrected by Jul 24, 2023

Category: recordkeeping. Marked corrected in the state record.

7.711.22.E · . For every thirty (30) or fewer children in attendance, there must be at least one (1) staff member with each group of children who holds current Department-approved First Aid and CPR for all ages of children. At any camp more than thirty (30) minutes away from emergency medical services, there must be at least one (1) staff member with each group of children qualified with a minimum of Wilderness First Aid Training, Department-approved CPR and Medication Administration Training. Staff members with Medication Administration Training must have annual delegation as required at section 7.711.22.b.3.

Reviewed 5 staff files and observed Hannah, Nathaniel, and Josephine to be missing documentation of First Aid/ CPR training. Identified through Director's statement that staff listed are with different groups of campers during the day. Correction: There must be at least 1 staff member wit each group of children who holds current Department-approved First Aid/ CPR training **Submit a written statement of compliance to specialist with response form by 7/ 31/ 2023. Correct by 07/24/2023

Corrected Corrected by Jul 24, 2023

Category: ratio. Marked corrected in the state record.

7.701.33.A.1 · Each applicant listed below must submit to the Colorado Bureau of Investigation (CBI) and the Federal Bureau of Investigation (FBI) a complete set of fingerprints taken by a qualified law enforcement agency or any third party vendor approved by CBI including county departments of human or social services that use fingerprint machines pursuant to Section 19-3-406(1)(C),(2), C.R.S., to obtain any fingerprint criminal history record held by the CBI and FBI. If a third party takes the individual’s fingerprints, the fingerprints may be electronically captured using CBI’s approved LiveScan equipment. Payment of the fee for the criminal record check is the responsibility of the individual being checked, identified as follows:

Reviewed 9 staff files and observed Joe and Quetzali to be missing documentation of CBI and FBI clearance. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Web page power-point. Submit verification that staff members Joe, Quetzali have reviewed the power-point within 24 hours. Submit documentation of (CBI, FBI, TRAILS, Or Out of State background check, Out of State Clearance Letters) for staff members Joe, Quetzali with written response to Specialist Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.42.B · . There must be maintained at the campsite a record for each staff member, paid or volunteer, which must include the following: Training, education, and experience of the staff member.

Reviewed 9 staff files and observed Joe to be missing documentation of education and experience Correction: Obtain documentation of experience and add to file **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023 Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: recordkeeping. Marked corrected in the state record.

7.701.53.A · . A child care facility must require each staff member of the facility to read and sign a statement clearly defining child abuse and neglect pursuant to state law and outlining the staff member's personal responsibility to report all incidents of child abuse or neglect according to state law.

Reviewed 9 staff files and observed Aliya and Michelle to be missing documentation of a signed child abuse statement. Correction: Obtain documentation of staff member have read and signed a statement clearly defining child abuse and neglect pursuant to the state law and outlining the staff member's personal responsibility to report all incidents of child abuse or neglect according to state law and add to files **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Marked corrected in the state record.

7.701.56.D · . All facilities, except family child care homes must post in every room of the child care facility, excluding bedrooms and living areas, the license capacity of the room and the staff-to-child ratio required by regulation to be maintained for the age of children cared for in the room.

the Louis Horst Hall, the Conrad room, and the art room to be missing capacity posting. Observed the Pavilion, the Louis Horst hall, the Conrad room, the Creative writing Room, the Art room, the Little Ballet room, the Fireplace room, and the Green room to be missing staff to child ratio posting. Correction: Add missing capacity and staff to child ratio postings to the rooms **Submit a written statement of compliance t specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: ratio. Marked corrected in the state record.

7.711.52.A · . All structures used by children shall be kept in good repair at all times.

A piece of wood on a step to the Top Notch cabin to be loose and coming off, posing a safety hazard. Observed several nails sticking out of the side of the Glen cabin by the door, posing a safety hazard. Correction: All structures used by children shall be kept in good repair at all times **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.22.C · . At any camps less than thirty (30) minutes from emergency medical services by vehicle, in clear weather, there must be at least one staff member with each group of children qualified with Department-approved First Aid, CPR, and Medication Administration Training and delegation.

Reviewed 9 files and observed Josephine, Michelle, Nathaniel, Hannah and Quetzali to be missing documentation of First Aid/ CPR training. Observed Joe, Ebany, and Quetzali to be missing documentation of medication administration training and delegation. Identified through Director statement that staff are in separate groups throughout the day. Correction: At any camps less than 30 minutes from emergency medical services there must be at least one staff member with each group of children qualified with Department approved medication administration training and delegation **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: ratio. Marked corrected in the state record.

7.711.22.D · . All staff members must complete a Department-approved Standard Precautions training prior to working with children. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 9 staff files and observed Josephine, Michelle, Nathaniel, and Hannah to be missing documentation of Standard Precautions training. Correction: Obtain documentation of Department-approved Standard Precautions training and add to files **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: recordkeeping. Marked corrected in the state record.

7.711.23.B · . At no time may a camper be left without qualified supervision. Sleeping quarters of the counselors must be within sight or hearing distance of the sleeping quarters of the children whom they supervise. Children may sleep alone for specific program functions such as solos or survival experiences and then only when regularly monitored pursuant to the camp's written program. The camp’s written program must include an audible mechanism for a camper to alert a staff member who is able to immediately respond. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

2 campers sleeping (feeling ill) in a cabin. There were no counselors in or around the cabin. Campers stated that the counselors knew where they were and were checking on them. Correction: At no time may a camper be left without qualified supervision **CORRECTED AT THE TIME OF INSPECTION. **CAMP NURSE CAME TO ESCORT CAMPERS TO THE NURSES/ MED CABIN 7/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: supervision. Marked corrected in the state record.

7.711.23.D · . In a residential camp, ratio of one (1) staff member having a supervisory role with children per number of campers must be maintained at all times as follows: 5 through 7 yrs. old = 6 children to 1 staff member, 8 through 10 yrs. old =8 children to 1 staff member, 11 through 13 yrs. old = 10 children to 1 staff member, 14 yrs. old and older = 12 children to 1 staff member.

2 groups of 14 campers supervised by 1 counselor in the Pavilion and the Louis Horst Hall. Campers were ages 14 years and older. Correction: In residential camps staff to child ratios of one staff member having a supervisory role with children per number of campers mus be maintained at all times as follows: 1: 6 for children 5-7 years of age, 1: 8 for children 8- 10 years of age, 1: 10 for children 11-13 years of age, and 1: 12 for children 14 years and older. **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: supervision. Marked corrected in the state record.

7.711.31.E · . The camper must submit documentation of immunization status or exemption as required by Colorado Department of Public Health and Environment (CDPHE). Colorado law requires proof of immunization or exemption be provided prior to or on the first day of admission.

Reviewed 10 children's files and observed 4 files to have immunization records on unapproved forms. Correction: Transfer immunization record to a Colorado Department of Public Health and Environment (CDPHE) approved form and add to file **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.701.32.A · . An operator of a licensed facility, guest child care facility as defined in Section 26-6-102 (16), C.R.S., or an exempt family child care home provider must submit a request to determine if an operator, applicant for employment or current employee has been found responsible for a confirmed report of child abuse or neglect in the State Department's automated system (Trails).

Reviewed 9 staff files and observed Joe, and Quetzali to be missing documentation of TRAILS abuse and neglect clearance. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Web page power-point. Submit verification that staff members Joe, Quetzali have reviewed the power-point within 24 hours. Submit documentation of (CBI, FBI, TRAILS, Or Out of State background check, Out of State Clearance Letters) for staff members Joe, Quetzali with written response to Specialist Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.52.E · . The aisles between rows of cots, beds, or bunks must be kept clear for exiting purposes. There must be at least two (2) feet of clear space separating sides of cots, beds or bunks.

The aisle between cots/ beds/ bunks in the Glen cabin, the Ranch cabin, the Cliff cabin, the Tent-a-Ment cabin, and the Top cabin the be less than 2 feet. Observed the ends of cots/ bunk (where the ladder is located), or the space between the cots/ bunks to have personal items/ luggage making exiting difficult in the Outlook cabin, the Hill cabin, Top cabin, the Cliff cabin, the Glen cabin, the Three trees cabin and the Ranch cabins. Correction: There must be at least 2 feet of clear space separating the side of cots, beds or bunks **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Marked corrected in the state record.

7.711.54.N · . Substances which may be toxic to a child if ingested, inhaled, or handled, including, but not limited to, poisons, drugs, medicines, insecticides, herbicides, rodenticides, bleaches, chemicals, and corrosive agents must be stored in a cabinet or enclosure located in an area not used by children, stored in the original container, and properly labeled.

A bottle of Clorox, a bottle of Bright Solution Cleaner, and a bottle of Green Clean in an unlocked cabinet under the sink in the Pavilion, accessible to children. Observed a bottle of Green Clean and a bottle of Mold Armor in an unlocked closet in the boys bathroom in boys circle, accessible to children. Observed a spray bottle of Fabreze on the counter in the staff bathroom in the Ranch Cabin. Observed a spray bottle of Wrinkle release, and a bottle of Myers FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ laundry soap on the shelf in the Top Notch cabin. Correction: Substances which may be toxic to a child must e stored in a cabinet or enclosure located in an area not used by children **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Marked corrected in the state record.

7.711.55.D · . Each separate building used for sleeping campers and each multistory building must be protected by a smoke detector on each floor of the building.

The smoke detectors in the Ridge cabin, the Cliff cabins to be missing batteries. Correction: Each separate building used for sleeping campers must be protected by a smoke detector **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.55.A · . Any fire extinguisher used at the camp must be of a dry chemical type, hung at a level readily available to staff members, and annually inspected by an approved inspector. Indian pump backpack fire extinguishers and fire extinguishers approved for use by the U.S. Forest Services are also acceptable.

The fire extinguishers at the kitchen/ dining hall, the art room, the Green room, the Creative writing room, the Main Studio room, the Conrad room, the Louis Horst Hall, the Little Ballet room, the Pavilion, the Barn, and all of the cabins to be expired. Correction: Any fire extinguishers used at the amp must be readily available to staff and annually inspected by approved inspector **Submit a written statement of compliance to specialist with written response by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.31.J.1 · Medication prescribed for campers must be from a licensed pharmacy; labeled with the name, address, and phone number of the pharmacy; name of the camper; name and strength of the medicine; directions for use; date filled; prescription number; and the name of the practitioner prescribing the medicine. When no longer needed or expired, the medication must be returned to the parent or disposed of properly.

An over the counter medication in the nurse's quarters to be expired. Correction: When no longer needed or expired, medications must be returned to the parent of disposed of **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023. Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

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

7.711.31.J.3 · All medication at the permanent camp site must be kept in a clean, locked container, except emergency medication such as epinephrine auto injectors or asthma inhalers. On excursions away from the camp, medication must be under the control of an adult and must be stored inaccessible to children.

Antibiotic ointment packets in an unlocked first aide kit in the Little Ballet room, Non-Aspirin Acetaminophen packets in an unlocked first aid kit in the Little Ballet room, Vapo throat drops on an open shelf in the Glen cabin, Tylenol packets and Neosporin ointment in an unlocked First Aid kit in the Ranch cabin, a bottle of CBD gummies, a bottle of Claritin, and a prescription medication on a dresser in the Cooks cabin. Obseerved Hydrocortisone cream and antibactertial cream on a counter in the staff bathroom in the Ranch cabin. Correction: Medications must be under the control of an adult and must be stored inaccessible to children **Submit a written statement of compliance to specialist with response form by 8/ 12/ 2023 Correct by 07/12/2023

Corrected Corrected by Jul 12, 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

Reviewed 9 staff files and observed Quetzali to be missing documentation of out-of-state background clearance Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Web page power-point. Submit verification that staff members Quetzali have reviewed the power-point within 24 hours. Submit documentation of (CBI, FBI, TRAILS, Or Out of State background check, Out of State Clearance Letters) for staff members Quetzali with written response to Specialist Correct by 07/12/2023

Corrected Corrected by Jul 12, 2023

Category: supervision. Marked corrected in the state record.