Beautiful Savior Lutheran School

2.229.C · Correction due November 12, 2025

In the back area of the stage in the gym, observed a container of "drydex" spackle and a container of caulk. Both items were labeled "keep out of reach of children"

Required correction: Items labeled "keep out of reach of children" must be inaccessible to children. Corrected at time of visit-staff moved items from the stage area of the gym and brought them to a storage area inaccessible to children on 11/12/25. No response required. Correct by 11/12/2025

2.229.L · Correction due November 12, 2025

In the #14 Preschool classroom, observed puzzle pieces that were small enough to fit in a choke tube.

Required correction: Toys accessible to children under 3 years of age must not be a choking hazard. Corrected at time of visit- staff removed items from the classroom, making them inaccessible to children on 11/12/25. No response required. Correct by 11/12/2025

2.237.H · Correction due November 12, 2025

In the stage area of the gym, observed multiple electrical out lets without protective covers or safety outlets.

Required correction: In rooms used by children, all electrical outlets that are accessible to children must have protective covers or safety outlets. Corrected at time of visit-staff placed protective covers over outlets in the stage area of the gym on 11/12/25. No response required. Correct by 11/12/2025

2.237.H

In the Toddler 2 classroom, observed the top outlet next to the entrance to be uncovered and accessible to children.

Required correction: In rooms used by children, all electrical outlets that are accessible to children must have protective covers or

2.127.D · Correction due January 19, 2024

Missing capacity posting in the gym and toddlers 1 classroom.

Required correction: Post ratio and capacity in all classrooms used for the care of children. Corrected at the time of visit: Staff posted capacity and staff-to-child ratio in gym and Toddler 1 on 1/19/24. No response required. Correct by 01/19/2024

2.216.B.2.b

During walk-through of Infant 2 classroom, observed A. and K. to be working alone with 5 children. Reviewed 14 staff files and observed neither A. nor K. to be ECT qualified.

Required correction: A qualified ECT or Infant program supervisor must be assigned to each group of ten or fewer infants in

2.138.A · Correction due January 19, 2024

Observed drill log and identified that fire drills were completed on 3/31/23, 4/21/23, and 5/1/23, and Tornado drills were completed on 5/10/23 and 8/31/23. No other drills were completed in 2023.

Required correction: Fire drills must be completed monthly. Tornado drills must be completed monthly from March to October. Other drills must be completed quarterly so that all drill types are practiced annually. Correct immediately and respond with a plan for ongoing compliance by 2/19/24. Correct by 01/19/2024

2.209.B.4 · Correction due February 19, 2024

Reviewed 5 child files, observed ch4's file to be missing current health statement completed by a health care provider.

Required correction: All child files must have a copy of the child's health statement completed by a health care provider in accordance with the American Academy of Pediatrics guidelines. Correct and respond with a statement of compliance by 2/19/24. Correct by 02/19/2024

Reviewed 14 staff files and observed ECT A. file to be missing documentation of 15 hours of ongoing professional development training annually.

2.127.C · Correction due January 19, 2024

Missing posting of complaint procedure in prominent and conspicuous location.

Required correction: Post complaint procedure in prominent and conspicuous location. Corrected at time of visit: Staff posted compliant procedure in a prominent and conspicuous location on 1/19/24. No response required. Correct by 01/19/2024

2.229.C · Correction due January 19, 2024

Inside bathroom of Toddler 2 classroom, observed the following items to be accessible to children and labeled "keep out of reach of children", posing a potential safety hazard: approximately 10 containers of diaper rash cream including "Boudreaux's Butt Paste" and approximately 5 packages of varying brands of baby wipes.

Required correction: Keep all hazardous items and items labeled 'Keep out of reach of children' inaccessible to children at all times. Corrected at time of visit: Staff stored items inaccessible to children on 1/19/24. No response required. Correct by 01/19/2024

On the "big" playground, observed a structure with 3 slides. The tallest slide had a gap of approximately 1 inch between the standing platform and slide, posing a potential safety hazard.

2.237.D · Correction due January 19, 2024

Observed loose cords longer than 18" to be accesible to children, posing a potentail safety hazard in the following locations: - Preschool room: blue stereo on staff desk - Jr. Pre school classroom: long white electrical cord next the coat shelves and changing table; refridgerator cord in the front of classroom; and 2 loose electrical cords at the back of the classroom under the black table.

Required correction: Keep all hazardous items inaccessible to children at all times. Corrected at time of visit- Hazardous items were stored inaccessible to children on 1/19/24. No response required. Correct by 01/19/2024

2.213.N · Correction due January 19, 2024

Identified through Director S.'s statement that she (S.), N., and S. are responsible for the collection, review, and maintenance of child immunization records. Reviewed 14 staff files and observed S. and S.'s files to be missing current documentation of completion of CDPHE immunizations training.

Required correction: Obtain current documentation of completion of CDPHE immunizations training for all staff responsible for the collection, review, and maintenance of child immunization records. Correct immediately and respond with verification of compliance by 2/19/24. Correct by 01/19/2024

Reviewed 14 staff files and observed A.'s file (DOH: 2/7/23) to be missing current health statement.