2.121.J.1 · 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-age child care facilities, family child care homes, and qualified exempt provider homes:

Reviewed 20 staff files and observed 2 staff member to not have documentation of out of state background checks. 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 Out of State Clearance Letters for staff members with written response to the Specialist Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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

Reviewed 20 staff files and observed 1 staff to not have documentation of emergency and disaster preparedness training. Correction: Obtain and maintain documentation of training in staff file. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

Category: recordkeeping. Marked corrected in the state record.

2.209.A.7 · An admission record must be completed for each child prior to or at the time of the child's admission. This record must be updated annually and when changes occur. The admission record must include: A dated, written authorization for emergency medical care signed and updated annually by the parent(s)/guardian(s). The authorization must be notarized if required by the local hospital, clinic, or emergency health care facility;

Reviewed 16 children's files and observed 10 children to need updated emergency medical authorization forms. Correction: Obtain and maintain documentation of updated emergency medical authorization forms for all children enrolled with expired forms. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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 20 staff files and observed 8 staff to not have health statements within 30 days of hire. Correction: Obtain and maintain documentation of current health statements for staff within 30 days of hire. Correct by 04/09/2026

Corrected Corrected by Apr 9, 2026

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

Reviewed 20 staff files and observed 6 staff with expired standard precautions trainings and 1 staff to not have documentation of training. Correction: Obtain and maintain documentation of current training. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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.

Reviewed 20 staff and observed 4 staff with expired safe sleep training. Correction: Obtain and maintain documentation of current training. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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 20 staff files and observed 1 staff with expired shaken baby. Correction: Obtain and maintain documentation of current training. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

Category: recordkeeping. 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, requests must be submitted and successfully completed prior to caring for children or allowing unsupervised access to children.

Reviewed 20 staff files and observed 4 staff to not have documentation of trails clearance letters. Correction: All individuals requiring a background check must review Navigating the Background

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

2.213.G · All employees and regular volunteers must be trained using a Department-approved training about Child Abuse Prevention prior to working with children, 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 20 staff files and observed 3 staff to have expired child abuse training. Correction: Obtain and maintain documentation of current training. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

Category: recordkeeping. Marked corrected in the state record.

2.213.K · Within ninety (90) calendar days of employment, all directors and assistant directors must complete the Department-approved training: Introduction to Child Care Health Consultation. This course is required once and will be counted towards ongoing professional development. FAX 303-866-4453 Phone 303-866-5948 ________________________________________________

Reviewed 20 staff files and observed 1 assistant director to not have documentation of the intro to child care health consultant training within 90 days of being a director. Correction: Obtain and maintain documentation of current training. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 04/09/2026

Corrected Corrected by Apr 9, 2026

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

2.218.C.5 · The individual health care plan must be updated at least every twelve (12) months from the date of the initial plan and as changes occur. The plan must include all information needed to care for the child, must be signed by the health care provider, parent(s)/guardian(s) and must include, but not be limited to, the following:

Reviewed children's health care plans and observed 2 children with expired health care plans. Correction: Obtain and maintain documentation of current health care plans. Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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

2.219.B.2 · Within thirty (30) calendar days of admission, and within thirty (30) calendar days following the expiration date of a previous health statement, the parent(s)/guardian(s) of each child must submit a statement of the child’s current health status or written verification of a scheduled appointment with a health care provider. The statement of the child’s current health status must be signed and dated by a health care provider who has seen the child within the last twelve (12) months, or within the last six (6) months for children less than two and one-half (2½) years of age. The statement must include when the next visit is required by the health care provider. All health statements must be kept at the center.

Reviewed 16 children's files and observed 7 children with expired health statements. Correction: Obtain and maintain documentation of current health statements within 30 days of enrollment and expiration. Correct by 04/09/2026

Corrected Corrected by Apr 9, 2026

Category: ratio. Marked corrected in the state record.

2.222.A.1.b · All diaper change areas must: Have a place inaccessible to children for storing all diaper change supplies and disinfecting solutions and products;

diapers on the back of a toilet in Preschool 1. Correction: Ensure all diaper supplies are stored inaccessible to children at all times. Correct immediately 3/9/26.

Open Not marked corrected in the state record

Open / not marked corrected.

2.229.L · Toys, toy parts, furnishings, equipment, and any materials accessible to children under than three (3) years of age must not be a choke hazard or able to be inhaled. Any area of the facility accessible to children less than three (3) years of age must be free of any choke or inhalation hazards.

in toddler A classroom to have dot markers with a lid that poses a choking hazard to children under 3. Correction: Ensure that all choking hazards are inaccessible to children under 3. Correct immediately 3/9/26. ***Corrected at time of visit, no response is required. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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

2.230.B · Indoor and outdoor equipment, materials, and furnishings must be sturdy, safe, and free of hazards.

a ripped diaper pad in prepper A, pour in place on the PRS playground to be repaired with what looks and feels like concrete and to be coming apart. Correction: Ensure all indoor and outdoor materials are sturdy, safe and free of hazards.Correct immediately 3/9/26 and submit compliance by 4/9/26. Correct by 03/09/2026

Corrected Corrected by Mar 9, 2026

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