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 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 Mengwe W have reviewed the powerpoint within 24 hours. Submit documentation of Trails 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 powerpoint 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 drill for day 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.

2.524.A.1 · Buildings must be kept in good repair and maintained in a safe condition.

Large wood pieces with screws under deck accessible to children posing a potential safety hazard. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Buildings must be kept in good repair and maintained in a safe condition. Correct by 06/19/2024

Corrected Corrected by Jun 19, 2024

Category: physical safety. 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 5 staff files and observed Joe, Quetzali, and Avery to be missing documentation of TRAILS abuse and neglect clearance. Observed Avery to be working with children (under supervision). Identified through Director's statement the he (Joe) supervises children at times, and that Quetzali supervises children at times. Observed a volunteer (Rusty) supervising a group of children alone in the fireplace room, and observeed Rusty to missing documentation of TRAILS 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, and Avery 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, and Avery with written response to Specialist. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. Marked corrected in the state record.

7.712.41.M · . All staff members and regular volunteers must complete a Department-approved training about child abuse prevention, including common symptoms and signs of child abuse within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 5 staff files and 1 volunteer file and observed Rusty (volunteer) and Avery to be missing documentation of child abuse prevention training. Correction: Obtain documentation of Department-approved training in child abuse prevention, including common symptoms and signs of child abuse and add to files **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.701.33.D.4.a · . Criminal background check requests must be submitted and successfully completed 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.

Reviewed 5 staff files and observed Joe, Quetzali, and Avery to be missing documentation of CBI and FBI clearance letters. Observed a volunteer (Rusty) to be supervising a group of children in the fireplace room alone. Observed Rusty to be missing documentation of CBI and FBI clearances. 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, and Avery 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 and Avery with written response to Specialist. **STAFF MUST HAVE A MINIMUM OF CBI TO WORK WITH CHILDREN, AND MUST WORK UNDER THE DIRECT SUPERVISION OF A STAFF MEMBER WITH A COMPLETE BACKGROUND CLEARANCE UNTIL CBI AND FBI ARE OBTAINED. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. 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.

Observed the facility to be missing a posting of its most recent licensing inspection report or a notice as to where the report may be reviewed at the facility FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Correction: Post the most recent licensing report or a notice of where it may be reviewed by the parent or legal guardian of a child **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Marked corrected in the state record.

7.701.56.C · . At all times during the operating hours of a family child care home, child care center, preschool, school age child care, children’s resident camp, and neighborhood youth organization, the facility must post in a prominent and conspicuous location information regarding the procedures for filing a complaint with the Colorado Department of Human Services, Division Of Early Care And Learning, including the telephone number and mailing address. All 24-hour care agencies and facilities providing out-of-home care and day treatment centers must post in prominent and conspicuous location information regarding the procedures for filing a complaint with the Colorado Department of Human Services, division of child welfare, including the telephone number and mailing address. For foster care homes and child placement agencies, information for filing a complaint must be made available upon request.

Observed the facility to be missing a post with information regarding the procedures for filing a a complaint with the Colorado Department of Human Services. Correction: Post in a prominent and conspicuous location information regarding the procedures for filing a complaint with the Colorado Department of Human Services, division of child welfare, including the telephone number and mailing address **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 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, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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.

Observed the art room, the fireplace room, and the to be missing licensing capacities. Observed the art room, the fireplace room and the Creative Writing room to be missing staff to child ratios. Correction: Post licensing capacities and staff to child ratios in each room **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: ratio. Marked corrected in the state record.

7.712.41.D · . Each staff member and regular volunteer as defined in section 7.712.44.C must complete an annual health history. The health history must be maintained in a secure location.

Reviewed 5 staff files and observed Quetzali and Avery to be missing documentation of a health histories. Observed Mary to be missing documentation of a current annual health history. Correction: Obtain documentation of annual health histories and add to files **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 08/11/2023

Corrected Corrected by Aug 11, 2023

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

7.712.41.F · . Prior to working with children, the staff member must read and be instructed on the policies and procedures of the center, including those relating to hygiene, sanitation, food preparation practices, proper supervision of children, and reporting of child abuse. Staff members must sign a statement indicating that they have read and understand the center's policies and procedures.

Reviewed 5 staff files and observed Quetzali and Avery to be missing documentation of a signed statement indicating the they have read and been instructed on the policies and procedures of the center. Correction: Obtain documentation of staff member's signed statement indicating that they have read and understand the center's policies and procedures and add to files **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. Marked corrected in the state record.

7.712.41.G · Day camp staff must receive a minimum of fifteen (15) hours of pre-camp training, in addition to FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ Department-approved First Aid and CPR. Pre-camp training must include all training activities that staff members participate in as a whole. Training should include, but not be limited to, familiarizing staff with the camp mission, site emergency policy and procedures, how to supervise and facilitate activities with campers, and health care policies and procedures. Policies and procedures must be in writing. Staff will be supervised and additional training may be provided if needed. Day camps must have a system in place to provide staff the essential training information for late hires.

Reviewed 5 staff files and observed Joe, Quetzali, Mary, Naomi, and Avery to be missing documentation of 15 hours pre-camp training. Correction: Day camp employees must receive a minimum of 15 hours pre-camp training. Obtain documentation of 15 hour pre-camp training and add to files **Send documentation of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. Marked corrected in the state record.

7.712.41.J · 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 Avery to be missing documentation of standard precautions training. Correction: Obtain documentation of Department-approved standard precautions training and add to file **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.41.L · . All staff member responsible for the collection, review and maintenance of the child immunizations records must show evidence they have completed the Colorado Department of Public Health and Environment (CDPHE) immunization course within (30) calendar days of employment. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 5 staff files and observed Joe to be missing documentation of immunization training. Identified through director statement that Joe collects children's paperwork. Correction: Obtain documentation of Colorado Department of Public Health and Environment (CDPHE) immunizations training and add to file **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: health medication. 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 5 staff files and observed Quetzali, and Avery to be missing documentation of emergency and disaster preparedness training. Correction: Obtain documentation of Department- approved training in emergency and disaster preparedness training and add to file **Send documentation of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.B.1 · . Each program leader must be at least 18 years of age, demonstrate ability to work with children, and must meet the following qualifications: Complete the Department-approved course in injury prevention;

Reviewed 5 staff files and observed Quetzali to be missing documentation of injury prevention training. Identified Quetzali to be sub director/ PL through directors statement. Correction: Obtain documentation of Department-approved course injury prevention and add to file **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.G.2 · . In a day camp, all staff members who are eighteen (18) years of age and older must have current Department-approved First Aid and CPR certificates. Uncertified staff members must work with another certified staff member.

Reviewed 5 staff files and observed Joe and Quetzali to be missing documentation of First Aid and CPR training. Correction: In a day camp, all staff members who are 18 years of age and older must have current First Aid and CPR training. Obtain documentation of current First Aid and CPR training and add to files **Send documentation of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.73.A.7 · Indoor and outdoor equipment, materials, and furnishings must be sturdy, safe and free of hazards.

The fire extinguishers on the side of the barn, the art room, in the kitchen, in the Creative Writing room, in the main studio to be expired. Correction: Indoor and outdoor equipment , materials, and furnishings must be safe, sturdy and free from hazards. Fire extinguishers must be updated **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023 Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

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

7.712.73.B.6 · Every building and structure must have an automatic or Department-approved manually operated fire alarm system to warn occupants of the existence of fire or to facilitate the orderly conduct of fire exit drills.

The smoke detector in the art room to be disabled ( laying on a shelf with the battery removed). Correction: Every building and structure must have an automatic or department-approve manually operated alarm system **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023 Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

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

7.712.52.A.1.b · . At the time of enrollment, the parent(s) /guardian(s) must provide for each child entering the center: Documentation of immunization status or exemption as required by Colorado Department of Public Health and Environment (CDPHE). Colorado law requires proof of immunization be provided prior to or on the first day of admission.

Reviewed 5 children's files and observed 1 file to be missing documentation of immunization records. Observed 2 files to have immunization records on an unapproved form. Correction: Obtain documentation of immunization records on (or/ and) transfer immunization record to a Colorado Department of Public Health and Environment approved (CDPHE) form by 8/ 11/ 2023. **Send a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 08/11/2023

Corrected Corrected by Aug 11, 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 5 staff files and observed Quetzali to be missing documentation of out of state background FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ clearance. Observed through paperwork that Quetzali has lived out of state in the last 5 years. 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 member Quetzali has 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 member Quetzali with written response to Specialist **STAFF MUST WORK UNDER THE DIRECT SUPERVISION OF A STAFF MEMBER WITH A COMPLETE BACKGROUND CLEARANCE (TRAILS/ CBI/ FBI/ OUT OF STATE) UNTIL OUT OF STATE BACKGROUND CLEARANCE IS OBTAINED. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. Marked corrected in the state record.

7.712.41.K · All staff members must complete a building and physical premises safety training prior to working with children. The training must include:

Reviewed 5 staff files and observed Joe, Quetzali, Mary, Naomi, and Avery to be missing documentation of building and physical premises safety training. Correction: Obtain documentation of building and physical premises safety training and add to files **Submit a written statement of compliance to specialist with written response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.42.B.3 · . Each program leader must be at least 18 years of age, demonstrate ability to work with children, and must meet the following qualifications: Must have at least three (3) months (460 hours) of full-time or equivalent FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ part-time satisfactory and verifiable experience with school-age children.

Reviewed 5 staff files and observed Quetzali to b missing documentation of verifiable experience with school aged children. Identified Quetzali as the sub director/ PL through Director's statement. Correction: Obtain documentation of verifiable experience with school aged children and add to file **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Marked corrected in the state record.

7.712.42.A.1 · The program director must have verifiable education or training in work with school-age children in such areas as recreation, education, scouting or 4-H; and the program director must have completed at least one of the following qualifications:

Reviewed 5 staff files and observed Joe (Director) to be missing documentation of qualifications. Correction: The program director must have verifiable education or training in work with school-aged children in such areas as listed above. Obtain documentation of qualifications and add to files **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.51.A · . The center can accept children only of the ages and capacity for which it has been licensed.

Identified through children's records and director's statement that the facility provides care for children ages 5 years to 12 years of age. The facility is licensed for children ages 8 years to 16 years of age. Correction: The center can accept children only of the ages and capacity for which it has been licensed **Submit a written statement of compliance to specialist with response form by 8/ 11/ 2023; Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

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

Facility to be missing documentation of current fire inspection. Correction: Obtain documentation of current fire inspection and post **Send documentation of current fire inspection to specialist with response form by 8/ 11/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

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

7.701.32.D.1.a · . 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 5 staff files and observed Joe (Director) , Quetzali, and Avery 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, and Avery 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, and Avery with written response to Specialist. Staff must work under

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

7.701.33.D.4.a · . Criminal background check requests must be submitted and successfully completed 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.

Reviewed 5 staff files and observed Joe (Director),Quetzali and Avery 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, and Avery 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, and Avery with written response to Specialist. **Staff must have a minimum of CBI or FBI to work with children. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: supervision. Marked corrected in the state record.

7.701.32.J · . 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 State Department for processing. An updated clearance letter or verification of the submission of the inquiry form must be obtained before prior to the five (5) years from the date reflected on the current clearance letter.

Reviewed 5 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 member Quetzali has 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 member Quetzali with written response to Specialist **Staff must work under the direct supervision of a staff member with a complete background clearance until out-of-state

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

7.712.42.B · . Program Leaders -Each program leader must be at least 18 years of age, demonstrate ability to work with children, and must meet the following qualifications:

Identified through director's statement that Quetzali is a Program Lead for the program. Reviewed staff files and observed Quetzali to be missing documentation of Program Leader qualifications. Correction: Obtain documentation of Program Leader qualifications and add to file **Send documentation of compliance to specialist with response form by 7/ 19/ 2023 Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Marked corrected in the state record.

7.712.42.A.1 · The program director must have verifiable education or training in work with school-age children in such areas as recreation, education, scouting or 4-H; and the program director must have completed at least one of the following qualifications:

Identified Joe as the Director for the facility. Reviewed staff files and observed Joe to be missing documentation of Director qualifications. Correction: Obtain documentation of Director qualifications and add to file **Send documentation of compliance to specialist with response form by 7/ 19/ 2023. Correct by 07/11/2023

Corrected Corrected by Jul 11, 2023

Category: recordkeeping. Marked corrected in the state record.

7.712.43.C · . There must be at least one (1) program leader providing supervision with each group of thirty (30) or fewer children cared for by the center. When four (4) year olds are in attendance, there must be at least one program leader providing supervision with each group of twenty-four (24) or fewer children cared for by the center.

Identified through Director statement that Quetzali was the Program Lead for a group of 15 children. Reviewed staff files and observed Quetzali to be missing documentation of Program Leader qualifications. Correction: There must be at least 1 program leader providing supervision with each group of 30 or fewer children cared

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.