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.

Reviewed facility emergency drill log and observed a 12 month history to be missing fire drills in the months of 8.2024, 10.2024, 12.2024 and 2.2025 Correction: A record of all emergency drills held over the past 12 months must be maintained by the facility. Submit plan of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: recordkeeping. Marked corrected in the state record.

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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ (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 22 staff files and obeserved H. Parker, S. Nelson, J. Kropp and E. Murphy to be missing CPR and First aid training. Correction: Obtain current documentation of CPR and First aid training, add to staff files and submit documentation of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

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 6 child files and observed 3 child files having expired authorization for emergency medical care. Correction: An admission record must be updated annually and when changes occur. A dated, written authorization for emergency medical care signed and updated annually by the parent(s)/guardians(s). Submit plan of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: health medication. 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 22 staff files and observed K. Salts, T.Peckham. and R. Hoffman having expired subsequent self reported health histories. Correction: Obtain current documentation of subsequent self reported health histories, add to staff files and submit documentation of compliance with written response. Correct by 06/08/2025

Corrected Corrected by Jun 8, 2025

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

2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 22 staff files and observed K. Salts and R. Hoffman to be having expired Standard Precautions training. Correction: Obtain current documentation of Standard Precautions training, add to staff files and submit documentation of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: recordkeeping. Marked corrected in the state record.

2.213.C · Staff working with infants less than twelve (12) months old must complete a Department-approved safe sleep training prior to working with infants less than twelve (12) months old. This training must be renewed annually and will be counted towards ongoing professional development.

K. Salts and R. Hoffman to be missing Safe sleep training. Correction: Staff working with infants less than 12 months of age must complete a Department approved safe sleep training prior to working with infants less than 12 months old. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: physical safety. 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.

R. Hoffman to be missing Prevention of shaken baby/abusive head trauma training. Correction: Obtain current documentation of Shaken baby/abusive head trauma training, add to staff file and submit documentation of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: recordkeeping. 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 FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ site director must be trained in the Department approved training.

Reviewed 22 staff files and observed G. Smith missining Emergency and Disaster preparedness training. Correction: Obtain current documentation of Emergency and Disaster preparedness training, add to staff files, submit documentation of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: recordkeeping. Marked corrected in the state record.

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.

R. Hoffmand and S. Nelson to be missing Child abuse prevention training. Correction: Obtain current documentation of Child abuse prevention training, add to staff files and submit documentation of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: recordkeeping. Marked corrected in the state record.

2.219.B.1 · At the time of admission, the parent(s)/guardian(s) must provide for each child entering the center: Documentation of school-required immunization status or certificate of medical or nonmedical exemption, is required by the Colorado Board of Health. Up-to-date school-required immunizations must be documented as specified on the Colorado Department of Public Health and Environment certificate of immunization or on an “approved alternate” Certificate of Immunization, defined in Colorado Department of Public Health and Environment rules located in 6 CCR 1009-2 rule section VI(A), (May 15, 2023), no later editions or amendments are incorporated. These regulations are available from the Colorado Department of Public Health and Environment at no cost at www.sos.state.co.us/CCR. These regulations are also available for public inspection and copying at the Colorado Department of Early Childhood, 710 S. Ash St., Bldg. C, Denver, CO 80246, during regular business hours. Colorado law requires proof of immunization status or exemption be provided prior to or on the first day of admission.

Reviewed 6 child files and observed 2 child files missing Colorado Department of Health and Environment certificate of Immunization record. Correction: Obtain current docuementation of Colorado Department of Health and Environment certificate of Immunization

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

2.220.G · All medications, except those medications specified in the Department-approved medication administration training as emergency medications, must be locked and inaccessible to children, but available to staff trained in administering medication. Controlled medications must be counted and safely secured, and specific policies regarding their handling require special attention in the center's policies. Access to these medications must be limited.

Over the counter medication accessible to children in unlocked cabinet by the sink in the preschool classroom. Correction: All medications except those medications specified in the Department approved medication administration training as emergency medications, must be locked and inaccessible to children. ***CORRECTED AT TIME OF VISIT*** Director removed the medication from classroom, making it inaccessible to children. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Category: ratio. Marked corrected in the state record.

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

Lotion labeled keep out of reach of children, accessible to children on low shelf in PreK and toddler classrooms. Wipes labeled keep out of reach of children, accessible to children in the pre K and preschool classrooms on low counters. Correction: Items labeled keep out of reach of children must be inaccessible to children. *** CORRECTED AT TIME OF VISIT***Director moved items to a locked cabinet in each room, making lotions and wipes inaccessible to children. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Marked corrected in the state record.

2.229.D · Staples must be inaccessible to children less than three (3) years of age.

Staples in bulletin board in hallway by the door to the preschool classroom, accessible to children less than 3 years of age. Correction: Staples must be inaccessible to children less than 3 years of age. *** CORRECTED AT TIME OF VISIT*** Director placed tape over staples. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Marked corrected in the state record.

2.229.H · Sharp tools and instruments must be stored in areas inaccessible to children.

Large roll of packaging tape with serrated edge, accessible to children in low unlocked drawer in the prek classroom. Correction: Sharp tools and instruments must be stored in areas inaccessible to children. *** CORRECTED AT TIME OF VISIT*** Teacher locked drawer, making them inaccessible to children. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

Marked corrected in the state record.

2.230.C.6 · All pieces of playground equipment must be designed to guard against entrapment and strangulation. Any openings in gross motor equipment above ground must be smaller than three and one half (3 ½) inches or greater than nine (9) inches to prevent entrapment.

More than a fingertips width gap between platform and climbing wall of playground equipment, posing a potential strangulation hazard. Correction: All pieces of playground equipment must be designed to guard against entrapment and strangulation. Submit plan of compliance with written response. Correct by 05/08/2025

Corrected Corrected by May 8, 2025

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.

Hand sanitizer labeled keep out of reach of children, accessible to children on low sink in the preschool room. Sanitizer spray labeled keep out of reach of children, accessible to children on low counter in preschool classroom. Correction: Items labeled keep out of reach of children must be inaccessible to children. Correct by 09/17/2024

Corrected Corrected by Sep 17, 2024

Marked corrected in the state record.

2.213.B · All staff must complete a Department-approved standard precautions training prior to working with children. This training must be renewed annually and will be counted towards ongoing professional development.

Reviewed 19 staff files and observed Brenda E., Kaurene S.,Hailey P., Tara P., to be having expired Standard Precautions training. Correction: Obtain current documentation of Standard Precautions training, add to staff files. Correct by 09/17/2024

Corrected Corrected by Sep 17, 2024

Category: recordkeeping. Marked corrected in the state record.

2.213.C · Staff working with infants less than twelve (12) months old must complete a Department-approved safe sleep training prior to working with infants less than twelve (12) months old. This training must be renewed annually and will be counted towards ongoing professional development. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Identified that Hailey P., having an expired safe sleep training. Correction: Obtain current documentation of Safe sleep training, add to staff file. Correct by 09/17/2024

Corrected Corrected by Sep 17, 2024

Category: physical safety. 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 19 staff files and observed Brenda E. and Hailey P to be having an expired Shaken baby/abusive head trauma training. Correction: Obtain current documentation of Shaken baby/abusive head trauma training, add to staff files. Correct by 09/17/2024

Corrected Corrected by Sep 17, 2024

Category: recordkeeping. Marked corrected in the state record.

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 19 staff files and observed Kaurene S., Hailey P. and Tara P., having an expired child abuse prevention training. Correction: Obtain current documentation of child abuse prevention training, add to staff files. Correct by 09/17/2024

Corrected Corrected by Sep 17, 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 19 staff files and observed Mary L., Lucas P. and Emily T. to be missing Introduction to the Early Intervention and Preschool Special Education training. Correction: Obtain documentation of Introduction to the Early Intervention and Preschool Special Education training, add to

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

2.213.I · 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 Recognizing the Impact of Bias on Early Childhood Professionals training or other Department-approved training on implicit bias. This course is required once and will be counted towards ongoing professional development.

Identified Lucas P., to be missing Recognizing the impact of bias training. Correction: Obtain current documentation of Recognizing the impact of bias training, add to staff file. Correct by 10/17/2024

Corrected Corrected by Oct 17, 2024

Category: recordkeeping. 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 19 staff files and observed no staff having Medication Delegation training. Correction: At least one staff member with the current department approved medication administration training and delegation must be on duty at all times. Correct by 09/17/2024

Corrected Corrected by Sep 17, 2024

Category: ratio. Marked corrected in the state record.

2.213.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 19 staff files and observed Kaurene S., Alaina W., and Mary L. missing CPR and First Aid module training. Correction: Obtain current documentation of CPR and First Aid module training, add to staff files. Correct by 10/17/2024

Corrected Corrected by Oct 17, 2024

Category: recordkeeping. Marked corrected in the state record.

2.217.C.7 · All Department-approved child care health consultants must complete the Department-approved FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ child care health consultant introductory training course within six (6) months of hire. Child care health consultants must complete Department-approved ongoing professional development training every three (3) years. The center must obtain and maintain proof of training completion.

Reviewed nurse file and observed Tracy R., to be missing Introductory Training Course. Correction: Obtain documentation of current Introductory training course, add to file. Correct by 10/17/2024

Corrected Corrected by Oct 17, 2024

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