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 and observed program lacking October tornado drill. Correction: Immediately (11/13/2025) ensure that all required drills are completed within the required time frames and documentation of each drill is maintained. Provide a written statement of compliance within the overall response. Correct by 11/13/2025

Corrected Corrected by Nov 13, 2025

Category: recordkeeping. Marked corrected in the state record.

2.511.C.5.a · -g The individual health care plan must be updated at least every twelve (12) months from the date FAX 303-866-4453 Phone 303-866-5948 ________________________________________________ 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 and parent(s) or guardian(s), and must include, but not be limited to, the following: a. Medication and dosing schedule; b. Nutrition and feeding instructions; c. Medical equipment or adaptive devices, including instructions; d. Medical emergency instructions; e. Toileting and personal hygiene instructions; f. Behavioral interventions; and g. Medical procedure/ intervention.

Reviewed (3) children's medications and observed (1) child lacking a current health care plan updated in the last 12 months. Correction: Immediately (11/13/2025) ensure that for all children with a health care plan that the program maintains documentation of a health care plan signed by a health care provider and the parent/guardian. Correct by 11/13/2025