2.126.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 10 staff files and identified Christy M., Zachary D., Savana B to be missing the Abuse form. Correction: All staff must sign the Abuse form. Submit a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

Marked corrected in the state record.

2.507.F · Unless medically contraindicated, staff members must be current for all immunizations required by their employer.

Reviewed 10 staff files and identified all staff to be missing a signed immunization statement. Correction: All staff must sign the immunization statement. Submit a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

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

2.508.D · Within (30) calendar days of employment all staff members and regular volunteers must complete 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 know child abuse or neglect. This training must be renewed annually and may count towards ongoing training requirements.

Reviewed 10 staff files and identified Zachary D. to be missing the Child Abuse prevention training. Correction: All staff must complete the training then update annually. Submit documentation with written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

Category: recordkeeping. Marked corrected in the state record.

2.122.A · Prior to the original license being issued, following the renovation of the facility that would affect the FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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.

Facility is missing report of a current Health inspection. Correction: Must obtain and maintain an approving inspection report. Submit documentation with a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 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 10 staff files and identified all staff to be missing the signature for fire extinguishers and fire alarm training. Correction: Each staff must be trained and sign a statement. Submit a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 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.

Reviewed drill logs for the 2024-2025 school year and identified that no fire and tornado drills were held in August, 2024. Correction: Fire drills must be held monthly and tornado drills must be held monthly from March through October. Submit a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

Category: recordkeeping. Marked corrected in the state record.

2.121.D · Each owner and employee sixteen (16) years of age or older of a facility or agency shall complete the fingerprint process at an approved vendor. Payment of the fee for the criminal record check is the responsibility of the individual being checked or the facility or agency. The results of the criminal record check, the CBI and/or Federal Bureau of Investigation (FBI) response letters, must be maintained at the home, center, facility, or agency and must be available for review upon request by a Licensing Specialist.

Reviewed 10 staff files and identified Kathy L. with expired FBI and CBI clearance letters, Dina Z. to be missing FBI and CBI clearance letters and Chelsie S., Zachary D., Meghan B., Savana B., Diana M., Kaitlyn M., and Zainab A. to be missing CBI clearance letters. Correction: All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage powerpoint. Submit verification that staff members have reviewed the powerpoint within 24 hours. Submit documentation of CBI and FBI Clearance Letters for Kathy and Dina and submit documentation of CBI clearance letters for staff members Chelsie S., Zachary D., Meghan B., Savana B., Diana M., Kaitlyn M., and Zainab A. with written response to the Specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

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

2.507.J · 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 10 staff files and identified 8 staff members to be missing the signed statement for medication administration policy. Correction: All staff must sign a statement that they been trained. Submit a written statement of compliance to specialist. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Category: ratio. Marked corrected in the state record.

2.507.K · Within thirty (30) calendar days of caring for children a signed statement indicating that the individual FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ has been trained, understands, and has had the opportunity to ask questions regarding the “Rules Regulating School-Age Child Care,” the “General Rules for Child Care Facilities,” and the “Rules Regulating Special Activities,” if applicable.

Reviewed 10 staff files and identified 7 staff members to be missing the signed statement for understanding Rules and Regulations. Correction: All staff must sign the statement. Submit a written statement of compliance to specialist. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Marked corrected in the state record.

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

Reviewed 10 staff files and identified Meghan B., Savana B., and Zachary D. to be missing one hour of child development training. Correction: All staff must have at least one hour of child development training. Submit a written statement of compliance to specialist. Correct by 03/27/2025

Corrected Corrected by Mar 27, 2025

Category: recordkeeping. Marked corrected in the state record.

2.513.E · In the case medication needs to be given on an ongoing, long-term basis, the authorization and FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ consent forms must be reauthorized on at least an annual basis. Any changes in the original medication authorization require a new written order by the prescribing practitioner and a change in the prescription label.

One child to be missing emergency medication and the consent form to be expired. Director first stated she does not know why is missing. Director then stated the child does not need the medication any longer. Correction: Any changes in the medication require a new order. Submit a written statement of compliance to specialist. Correct by 02/27/2025

Corrected Corrected by Feb 27, 2025

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

2.524.A.3 · Volatile substances, such as gasoline, kerosene, fuel oil, and oil-based paints, firearms, explosives, and other hazardous items, must be stored away from the area used for child care and be inaccessible to children.

Hand sanitizer on a table in the cafeteria labeled "keep out of reach of children" accessible to children and posing a potential safety hazard. Correction: Items labeled "keep out of reach of children" must be inaccessible to children. Corrected at the time of the inspection. The Director removed the items from within reach of children. No response is required. Correct by 04/02/2024

Corrected Corrected by Apr 2, 2024

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

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, FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ requests must be submitted and successfully completed prior to caring for children or allowing unsupervised access to children.

Reviewed four staff records and observed one staff member (Nikki K. DOH 12.4.2023) to be missing documentation of any of the required background checks. Observed NIkki to be working with children. Observed documentation of the required Trails background check to be missing from Jordan F. (DOH 8.8.2023), and Grace K. (DOH 3.1.2023) records. Correction: Obtain background information for all staff as required and prior to working with children. Correct immediately, and submit a written statement of compliance and documentation of the required background check to the Specialist by 5.2..2024. Correct by 04/02/2024

Corrected Corrected by Apr 2, 2024

Category: supervision. Marked corrected in the state record.

2.121.D · Each owner and employee sixteen (16) years of age or older of a facility or agency shall complete the fingerprint process at an approved vendor. Payment of the fee for the criminal record check is the responsibility of the individual being checked or the facility or agency. The results of the criminal record check, the CBI and/or Federal Bureau of Investigation (FBI) response letters, must be maintained at the home, center, facility, or agency and must be available for review upon request by a Licensing Specialist.

Reviewed four staff records and observed staff member Jordan F. (DOH 8.8.2023) to be missing documentation of the required CBI, and Nikki K. (DOH 12.4.2023) to be missing documentation of the required FBI and CBI background checks. Correction: Obtain the required background checks for all staff as required. Correct by 4.2.2024, and sumbmit a written statement of compliance and documentation of the background check to the Specialist by 5.2.2024. Correct by 04/02/2024

Corrected Corrected by Apr 2, 2024

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

2.121.D.4.a · Criminal background check requests must be 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-age child care facilities, family child care homes, and qualified exempt provider homes.

Reviewed four staff records and observed one staff member Nikki K. (DOH 12.4.2023) to be missing documentation of the required criminal record checks CBI and FBI background checks. Observed Nikki K. to be working with children. Correction: Obtain the required background checks for all staff as required. Correct by 4.2.2024, and sumbmit a written

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

2.508.D.3 · The center must maintain documentation including the child care health consultant’s Department of Regulatory Agencies (DORA) proof of active licensure in good standing, by the Colorado Medical Board or State Board of Nursing as a physician or registered nurse, a brief biography highlighting applicable knowledge, experience and approximate dates worked as a school nurse or Child Care health Consultant commenced.

Documentation of the health care consultants' qualifications to be missing. Correction: Obtain documentation of the required health care consultants' qualifications. Correct by 5.2.2024, and submit a written statement of compliance and documentation of the qualifications to the Specialist. Correct by 05/02/2024

Corrected Corrected by May 2, 2024

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

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

Documentation of the health care consultants' Colorado Department of Public Health and Environment Immunization training to be expired, observed documentation of the last completed course was in 2020. Correction: Obtain documentation of the required health care consultants immunization training course. Correct by 5.2.2024, and submit a written statement of compliance and documentation of the qualifications to the Specialist. Correct by 05/02/2024

Corrected Corrected by May 2, 2024

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

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. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ These reports must be maintained at the facility and be available for review upon request by a Licensing Specialist.

The most record fire inspection to be missing, observed the most recent fire inspection to have occurred in 2021. Correction: Obtain documentation of the most recent fire inspection report from the local fire department. Correct by 5.2.2024, and submit a written statement of compliance and documentation of the approving inspection report to the Specialist. Correct by 05/02/2024

Corrected Corrected by May 2, 2024

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

7.712.83.A.2 · The following records must be on file at the center: Current health department child care inspection report issued for the assigned license number within the past two (2) years;

The facility is lacking the most recent health inspection report. The most recent health inspection report was dated 3/21/2021. Correction: Obtain an updated health inspection report and submit documentation with the written statement of compliance. Correct by 09/05/2023

Corrected Corrected by Sep 5, 2023

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

7.712.42.G.3 · All employees caring for children, not required by rule to be certified in First Aid and CPR, must complete a Department-approved basic First Aid and CPR module within thirty (30) calendar days of employment and the module must be renewed every two (2) years. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 4 staff members' files, two files (Iule M. and Karen) are lacking documentation of First Aid and CPR training or the basic first aid and CPR module. Correction: All employees caring for children, not required by rule to be certified in First Aid and CPR, must complete abasic first aid and CPR module within 30 calendar days of employment and the module must be renewed every 2 years. Submit documentation with the written statement of compliance. Correct by 10/05/2023

Corrected Corrected by Oct 5, 2023

Category: recordkeeping. 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 4 staff members' files, one file (Grace K.) is lacking documentation of the department approved standard precautions training. Correction: Immediately (9/5/2023) ensure that all files have documentation of the department approved standard precautions training. Submit documentation with the written statement of compliance. Correct by 09/05/2023

Corrected Corrected by Sep 5, 2023

Category: recordkeeping. 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 members' files, two files (Grace K. and Karen N.) are lacking documentation of the department approved training in emergency and disaster preparedness. Correction: Immediately (9/5/2023) ensure that all files have documentation of the department approved training in emergency and disaster preparedness. Submit documentation with the written statement of compliance. Correct by 09/05/2023

Corrected Corrected by Sep 5, 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 4 staff members' files, one file (Grace K.) is lacking documentation of the department approved injury prevention training. Correction: Review all staff members files, ensure all files have documentation of the department approved injury

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

7.712.81.A.8 · The center must maintain and update annually a record on each child that includes: A dated written authorization for emergency medical care signed and submitted annually by the parent or guardian. The authorization must be notarized if required by the local health care facility;

Reviewed 4 children's files, all four files are lacking documentation of the emergency medical authorizations. Correction: Immediately (9/5/2023) review all children's files, ensure that all files have updated emergency medical authorizations signed and dated by the parent or guardian. Correct by 09/05/2023

Corrected Corrected by Sep 5, 2023

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