Sarah Embleton

2.121.D.4.a · Correction due May 5, 2026

Reviewed four staff records and observed two staff record's to be missing documentation of the required CBI and FBI background checks. Identified that the two staff members to be caring for children, posing a potential safety hazard.

Required correction: Obtain the required background checks as required for all staff members. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by 05/05/2026

2.312.F

Reviewed four staff records and observed two staff members to be missing documentation of the required building and physical premises training, posing a potential safety hazard.

2.121.D.5 · Correction due May 5, 2026

That adult members of the home to be misssing documentation of current FBI and CBI background checks and posing a potential safety hazard.

Required correction: Obtain the required background checks as required for adult members of the home. 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 Power Point within 24 hours. Correct immediately by 5.5.2026, and submit documentation of the required Trails background check to the Specialist by 6.5.2026. Correct by 05/05/2026

2.121.J.1.a

One staff member to identify that they have lived outside of the state of Colorado in the past five years. Observed the staff member to be working with children, and posing a potential safety hazard.

Required correction: All staff members who have lived outside of the state of Colorado must obtain an out of state background check. All individuals requiring a background check must review Navigating the Background Check Investigation Unit's (BIU) Webpage Power Point. Submit verification that staff members have reviewed the Power Point within 24 hours. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by

2.138.A · Correction due June 5, 2026

Identified through staff statements that they have not documented emergency drills, posing a potential safety hazard.

Required correction: Emergency drills must be completed and documented as required. Correct immediately by 5.5.2026, and submit a written statement of compliance and documentation of the drill log to the Specialist by 6.5.2026. Correct by 06/05/2026

2.312.C · Correction due May 5, 2026

Reviewed four staff records and observed three staff members to have expired Standard Precautions training, posing a potential safety hazard.

Required correction: All staff must complete the required Standard Precautions training as required. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by 05/05/2026

Reviewed four staff records and observed two staff record's to be missing documentation of the required Trails background check.

2.312.G · Correction due May 5, 2026

Reviewed four staff records and observed one staff member to be missing documentation of the required shaken baby/ abusive head trauma training, posing a potential safety hazard.

Required correction: Obtain the required shaken baby/ abusive head trauma training for all staff as required. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by 05/05/2026

2.312.H

Reviewed four staff records and observed three staff members to be missing documentation of the required prevention of child abuse training, posing a potential safety hazard.

2.312.I · Correction due May 5, 2026

Reviewed four staff records and observed all four staff members to be missing documentation of the required safe sleep training, posing a potential safety hazard.

Required correction: Obtain the required safe sleep training for all staff as required. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by 05/05/2026

2.312.J · Correction due May 5, 2026

The staff member who is responsible for collecting children's immunizations records to be missing documentation of the required immunization training from their record.

Required correction: Obtain the required immunization training for staff who are responsible for the collection, review, and maintenance of immunization records. Correct immediately by 5.5.2026, and submit a written statement of compliance to the Specialist by 6.5.2026. Correct by 05/05/2026

2.321.A.2.c

Reviewed children's files identified three children's records to be missing Immunization records.

2.321.A.3 · Correction due June 5, 2026

Reviewed children's files and identified three children's records to be missing health statements.

Required correction: Maintain updated health statements. Submit a written statement of compliance by 6/5/2026. Correct by 06/05/2026

2.138.A · Correction due May 30, 2024

Reviewed drill log. Observed missing fire drill from January to March. Observed missing tornado drill from March and April. Observed missing lockdown drill from the first quarter of 2023.

Required correction: Immediately, fire drills must be held monthly. Tornado drills must be held monthly from March to October and lockdown drills must be held quarterly. Submit a written statement of compliance by 6/30/2024. Correct by 05/30/2024

2.120.C.1.a

Observed C.S., K.R., C.H., and K.M. missing documentation of TRAILS clearance. None of the staff members were alone with children at the time of visit.

2.133.A · Correction due May 30, 2024

Reviewed 5 staff files. Observed K.R., hired 6/1/2023, and C.H., hired 5/28/2024 missing current documentation of a training in emergency and disaster prepardness.

Required correction: Prior to caring for children, all staff must complete a Department-approved training in emergency and disaster preparedness. Submit documentation and a written statement of compliance by 6/30/2024. Correct by 05/30/2024

2.312.C

Reviewed 5 staff files. Observed K.R., hired 6/1/2023, and C.H., hired 5/28/2024 missing current documentation of a standard precaution training.

Required correction: Prior to working with children, all staff members must complete a Department-approved training in standard

2.312.D.1 · Correction due May 30, 2024

Reviewed 5 staff files. Observed C.H., hired 5/28/2024 missing documentation of First Aid and CPR.

Required correction: Prior to working with children, all staff members must complete the Department-approved First Aid and CPR module. Submit documentation and a written statement of compliance by 6/30/2024. Correct by 05/30/2024

2.312.G · Correction due May 30, 2024

Reviewed 5 staff files. Observed C.H., hired 5/28/2024 missing current documentation of a shaken baby/abusive head trauma training.

Required correction: Prior to working with children less than three (3) years of age, all staff members must complete a department-approved prevention of shaken baby/abusive head trauma. Submit documentation and a written statement of compliance by 6/30/2024. Correct by 05/30/2024

2.312.H

Reviewed 5 staff files. Observed C.H., hired 5/28/2024, missing current documentation of a training about child abuse prevention.