Arapahoe County Board of Health - Regular Meeting

We're about to get started.

We're weighing this group in.

Yes. Monitor, monitor.

Yes, the rule follower. Never going to let that down. Good afternoon. I'd like to call the Arapahoe County Board of Health business meeting to order. Ms. Banks, will you please call the roll?

Director B.B. Kleinman. Here. Director Sean Davis.

Here.

Director Christine Burroughs. Here. Director Mark Levine.

Here.

Director Mark McMillan.

Here.

Director Terrence Walker.

Here.

And Director Michelle Wynote.

Jesus, that's an excuse. I would now like to ask the directors in the room to introduce the staff that are present today.

Our financial operations business manager. Tracy.

We'll go through. We have Melissa Oloso, our communicable disease epidemiology manager.

We have Dylan Garrison, environmental health manager. Josh Stakes, environmental health supervisor. Okay. Juanita Rodriguez. She just started on Monday, our new senior healthy building specialist. It was an approved position a couple years ago, funded this year, so we're really excited. Kristen Beyer, business operations manager. Steve Chevalier.

Who's that? He's asking to stand right there.

At least Danielle Henderson, environmental health supervisor.

Well, large team.

Yeah, we brought everybody today. I'd like to quickly introduce our new chief medical officer. So if we could just give it a couple of minutes just to briefly share with you all his experience. And we're really excited to have him just started. We made the transition June 1.

Yes. Very good. So, yes, I'm Paul Mayer, a family physician by training, and worked for over 20 years as a family physician, first in Rango in a private practice, and then I've gotten into community health work. It's been about 20 years in the community health setting, and mostly and specifically in migrant and seasonal farm worker clinics. I am reasonably bilingual in Spanish, I wouldn't say fluent, but I rarely meet an interpreter because it's And I did sort of full spectrum family medicine, did inpatient medicine, I did obstetrics, delivered babies for about 20 years, about 600 babies or so. And then was here at Salud, which is at FQH. And then from that, kind of worked a bit just perfectly really with the health department and then jumped at a job that was advertised there in 2021. So February of 2021, I got into public health. Okay. And then I've been the chief medical officer for Larimer County since then. And then I just followed Chris around, so he was there. And then he was working at El Paso, and I was filling in for him for vacations. And then when he left El Paso, I interviewed him and took the job in El Paso, and I still work at El Paso. And then he was here, and I was filling in for Chris. And then came just to start his first job. No, along the way, I've done a variety of things. I was an in-house physician for a long-term care facility, of course, for a while. I drove an ambulance when I was 18, about four years. And I was the director of emergency care for UC Health for about three years, just sort of mixed things. Originally, I'm from Northern California, a small town in Northern California, north coast of Redwoods, you've got Arcata.

Wow.

HID care for about five years.

I would just tell you the most important thing, Jennifer and team communicated, you did excellent, had an excellent background and it was a unanimous choice. So they were very pleased. And so normally the board says, if the staff agrees, the board is on board. So welcome and we look forward to working with you.

We still follow Chris into retirement.

Our next agenda item is to approve the May minutes. Can I get a motion to approve the May 2026 meeting minutes as presented? So moved.

Second. Second.

Okay. Motion made by Mark Levine and seconded by Christine Burroughs. Next is our public comment period. You're invited to speak to the Board of Health about any topic. Ms. Stinks, do we have anybody in the queue? After the interesting conversations. Next is the director's time. And at this time, I'm going to ask my fellow board members to share insights from community leaders and partners to gauge the current state of the community. And I'll go left to right starting with parents.

No big updates for me, but just a reminder, Juneteenth is a Friday. It is an important day to a lot of folks. And in my opinion, if you're around parents, people who take us to the holiday series and black people just like acknowledge the knowledge of the day, acknowledge the importance of the holiday to the people who it's important to. So just a reminder that we're an issue team.

For my agency, City of Canada Denver, we're focused on a number of things and seeing a lot of engagement with some of the underrepresented communities as we get into some potential role-making. and trying to be really intentional there, meet people where they're at and so forth. So pretty early in the process, specifically we're looking at revising our odor ordinances and that there's some pretty big impacts from facilities like Suncor and Purina and other industrial facilities. So looking forward to some listening sessions coming up just in the next couple of weeks. And we anticipate we'll be meeting with the regular community at some point too, but hearing from the community and those who live in those areas can be really important. So looking forward to that.

This morning, I heard a story or I told a story to my board of directors at Doctors Care. And it was just new learning for me or something I just didn't realize the impact of HR1. And it's a story about a man, high blood pressure. And he has been, he's legally in the country, but under the five-year bar, but low income. He has a pregnant wife and three other children and the children have Medicaid. and the wife has tuberculosis because she's pregnant. But he lost the subsidy because he's under the five-year bar and he no longer can get a subsidy. So now he is fully uninsured because he couldn't possibly buy insurance. The cheapest plan available to him was $400 a month with an $8,000 out of pocket. So like having no insurance. I just... I think that just beginning to see the role out in real human lives has been surprising and sad in some ways. And here's a man that has to support his family because these people would be homeless if he wasn't out working. And he's done everything right. So here's a person who's trying to do everything right. And he doesn't get a subsidy. If his income was higher and he could buy insurance or if it was above the Medicaid rate, he could get some. There's just all these little pieces of what's happening that people are going to just fall through all these cracks. And it was just an interesting perspective that I think we're now beginning to see the role of. But that's really my story.

Yeah. Well, as Karen said, June is Pride Month and also Juneteenth. But two years ago, I had the luxury around Juneteenth of meeting with Martin Luther King Jr.'s chief of staff, the wife of the chief of staff. She's about 90 years. 94 now and she was also one of the original freedom fighters and so in a lot of the conversations uh i always communicate part of what i ask is how were things back then have things changed and she was like one of the things that i think people miss is understanding how much progress has been made she said we fought for civil rights we wasn't fighting for equality we were fighting to be able to go into the same door as white people, to go into the same room, to sit at the same lunch counter. And she said, you know, all of the disagreements with the freedom fighters, she said, we took the pledge to basically lose, put our life on the line. So that was the consequence. So she said, just understanding that. when she said, when y'all young generation, and I'm, you know, mid-50s, so I was like, thank you. I'm young, but she said, really what she pressed upon me was spending more time helping the younger generation understand truly how much progress had been made and all of the people that gave their life And bought for the calls all the way back to the abolitionists who we don't acknowledge as much. So I just tell people while it's an ongoing issue, a lot of progress has been made. So, during this time, that's 1 thing. I'm really thankful.

Yes, yes. This were Monday.

I would be, I had intended to come and talk about what I think is a public health issue that we can help with. And that is, there are so many people in Arapahoe County with hypertension who don't know that they have hypertension. And I was thinking, well, gosh, maybe I should be suggesting that we should have some kind of a program where we help people to realize what their blood pressure is, get them into health care and go from there. Unfortunately, I did some research. And it turns out that those kinds of programs sound wonderful, but they're very difficult to make worthwhile. in the sense that taking just a random blood pressure on someone can be misleading because of white coat syndrome or one thing or another. And that to really understand if someone has blood hypertension, you need a series of blood pressures over time and everything like that. And even if you, apparently the research has shown that if you do identify someone who is not already in medical care, and you tell them that they have and show them that they have hypertension, the net result is not very good. They really need to be in care, in medical care to do that. So I'm not suggesting.

Your turn.

Well, I have been on vacation for the last week and a half, so I don't have a ton to report on. However, I just read some really good books. One was not a beach read, but it's called There's No Place for Us, and it's about working homelessness in America. I highly recommend it. Do not read it on the beach. It is not a good beach read, but it follows these five folks and families in Atlanta and how they're just trying to get through the system. It was pretty... like horribly enlightening. I'm not sure I'm selling it. It was a great book, but like one that you sort of have a hangover from afterwards. And I'm tearing through the line, women of Tehran, if you're also looking for another one.

So yeah, that was more beachy, not that beachy, but still more. Really quick to that because our, our exec team has been trading, uh,

More audio books, but two I would highly recommend is Everything is Tuberculosis. Fabulous. And then Revenge of the Tipping Point.

Great as audio books, both of them.

We should get a list started.

I know. We should. Public health books. Yes.

And we're going to start off with a movement to our general business. Our 1st item is a hearing to approve the proposed environmental health fees increase in Kristen. It's going to be our presenter.

Okay, now we're talking about.

All right, here we go.

So why we're here is because we have not updated fees that we've been charging since 2019. We basically just adopted the fees for the prior health organization. We didn't have any data to base any changes on until now. We've completed the review process. We've looked at the cost to deliver the services. We've reached out to the community and asked them what their priorities are so that we could consider them as we're making recommendations for adjustments to fees. We analyzed all of this information and we, two months ago, came to the Board of Health and made some recommendations.

The purpose of the adjustments are really to improve the cost of recovery to support. There we go, all right.

The fiscal impact varies between about 35K and 80K. Some of them are stepped up over those three years. The potential effective date would be January 1st. ACPH is recommending that the Board of Health conduct a public hearing and adopt the proposed fees as they've been presented. And I understand we need to have a motion to vote for this. So I will hand that over to the person in the center. Okay.

Yeah, so I moved for the Board of Health to approve and adopt the proposed environmental health fees to be effective January 1st, 2022. Can I get a second? Second by Mark. All in favor, say aye. Aye. Any opposed? Hearing none, motion passes. Excellent work. Thank you.

Thank you.

We're going to now move into our study session time. The first study session is the 2027 draft budget. Brianna's going to be presenting on the budget.

Oh, good afternoon.

Thank you. All right.

And actually, I'm going to do quarter one of 2026 financial update as well, as well as the preliminary budget review. Oh, my goodness.

I have no slide deck in order. We will just roll with it.

So for collective revenue, we are at 52%, and there's a very specific reason for this. We have collected 100% of our county contribution, which is $8.5 million. And then we've also collected all of our retail food license renewal fees. So those were, we issued the invoices at the end of the previous year. It's deferred revenue primarily. We collected and recognized it at the beginning of the year. So obviously that percentage will correct it. From an expense standpoint, we're perfect. We're 25% of the way through the year. We're 25% of the way through the expenses. So that's always like my anxious moment as we're preparing these. I'm like, oh, perfect. trending right there um looking at the um financial summer financial summary the fees for service so that's where you're going to see the retail food license fees again the 65 is because we've collected those renewal fees already medicaid and insurance reimbursements we're actually seeing a trend up we will continue to monitor that obviously we have no way to project last year was our first complete year of actually collecting Medicaid revenue. Previous to that we were back billing so it was very hard to see what trends we might anticipate. So this is a positive trend. I'm very extremely cautiously optimistic about this because of the Medicaid provider rate cut that the state is going to utilize. You'll see our federal grants are trending right on at 25% just under. And then our state grants are a little bit below that. The reason for that is we have several hybrid grants where we receive funding from in the same grant from two streams. One's partially federal, partially state. The federal funding always has a shorter time period. So we heavily utilize those funds first and then move to the state. So again, it levels out throughout the year, but that's why you're seeing that. And then you'll see our county contributions at 100%. So we've received all of the funds the county gave to us in the 2026 budget request. On the expense side, you're going to see we're spot on. We have a couple of pieces that come from the county that we haven't seen any expenses yet and that's just part of the process and it's normal.

So we are right where we expect it to be. Looking at the

High charts, just a reminder. These are actuals not budget. So that's why the county contribution is such a high amount at this point. And then we'll see that percentage correct itself and then the constant reminder and it's very relevant as we head into the budget presentation. We are at 85%. We've maintained that trend of personnel being our 85% of our total expenses. So that includes salary in our total comp packages. And I do think I skipped a slide. I wasn't actually out of order, was I? Funding landscapes. I was not out of order. I apologize. Okay. So we do want to review this because there are pieces to this that impacts all of it and specifically around the budget. So we have the ongoing instability at the federal level. The state has not gotten notice of awards for some of our key contracts, specifically around immunizations, Title X. So we receive notices, and you'll see this noted throughout the presentation, notices of award for our state side of the funding, but not our federal side. So that's why we continue to bring this up, because we don't yet know. Anytime that the state, or I'm sorry, that the federal government presents any form of the budget, it's incredibly difficult to weed through what's been funded, what's been reduced. And so it continues to be an aspect of that. I've noted the CFR Part 200 proposal changes. I'm not sure if anyone caught this, but there was a, they released the OMB, which is the Federal Office of Budget Management, released proposed changes to this. And this is our governing document for how we account for allowable expenses. It's kind of our, we go to this all the time. If it's referenced in there, we have to follow it from an expense and accounting and budgeting side. There were some very key aspects to those changes that give me concern, not necessarily from our side, although there's some things that could be concerning. It's very much from the state side as far as if the state will continue to accept certain federal funds, specifically around, it's very bizarre wording, but that if you accept federal funds, there's restrictions on the use of your property, things like that. It's incorporating a lot of the, Executive decrees, that's not the word, and I can't think of it.

Priorities.

That were issued over the last several years. It's codifying those into these rules. And so, again, not necessarily from Arapahoe County side, although I can't speak to what they may decide to do. I am concerned from the state side whether the state will continue to accept certain federal funds. So that's why it just adds to that level of uncertainty.

Is that like the DEI work? Yes. So if the state... says we're not going to take that money because we're not going to limit this. Correct.

Partially why we've had such delays in our contracts from the state is because they're heavily reviewing those contracts from the feds. So, yeah, it's concerning. Yeah. And then we have obvious, and I know many of you deal with this acutely, this continued uncertainty at the state budget level. So they have not structurally corrected the state budget issue. We are continuing to see a projected $1.5 billion deficit each year. And I would anticipate that's going to continue to grow. So from our standpoint, our grants are going to be at least flat funded, we can anticipate, or maybe small or additional decreases. And you'll see that again reflected in the budget that we propose.

Can I add some clarification on that? If the state has to have a balanced budget, how would... Are we going to know it's a great question for it to grow?

So they have been balancing the budget each year on certain, I call them levers. So they pull different levers. In some cases, they're moving cash fund reserves to fund one time ongoing expenses. Okay. And so we don't have probably a better way to say it is that there isn't an ongoing balanced budget. There's that one point in time.

Okay.

And so are the CalFO, A lobbyist calls it funny money. So sometimes it's moving money from one place to another in that moment. So that's why. And so that's what the structural balancing means.

Thank you.

Yes. As we've gotten our renewals for many of our state contracts, we're seeing flat funding or renewals. Small decreases, so we kind of we talk about this as our death by 1000 paper cuts where we're like, yes, it's only a 3000 dollar decrease except for it's been 3000 dollars on 5 grants now, or it's 3000 dollars over several years. And again, we'll go into more depth in the presentation on that. But that's what we're looking at. We have had decreases in several of our key programs specifically our harm reduction program. has had significant cuts. Our immunizations state funding had a cut, which is the core immunizations funding. And then our sexual health programs have had, again, the incremental cuts over several different grants that accumulate into an issue. And then as a reminder, I feel like I've been saying this for years, but we've had this kind of situation several years over, year over year now. So we are working on a, report basically to show how that has happened over the years and to show what the actual aggregate impact is. Okay, now we're back.

Just one question on the previous one. What percentage, if you had to give a percentage to the staff anxiety, what number would you?

We continue to hear it. I'm not sure that I feel comfortable giving a percentage, but it's not zero. I hear it on a very regular basis that there is a concern for continued funding around and their position stability. Okay. Okay.

And we see it. If you look at the survey, it kind of shows up. We do the quarterly survey, and we can see major dips in time where budget conversations start, where the weekends come. And the question that we ask, I think it's something that I feel good about the future. Last summer, right before the commissioners went out for the 1A ballot initiative, And we just plummeted, and we could exactly pinpoint that these are budget conversations and some of the comments to talk about. Like, there's just a lot of fear of, is my job stable? Will I have a job? Is the funding stable? Because we hear and feel everything that's coming from the feds to the state to local. So, yeah, I'm not sure of the percentage, but we could absolutely pull out some information that is directly from the staff and the summaries.

Well, I know last year, I believe it was last year, when we went into executive, when we had our meeting and we talked about it. And so just knowing, is there anything we can do to try to help alleviate some of that, you know, anxiety among the staff? Because, you know, we've communicated as a board that we're our priority is, you know, on the budget is for the staff. And so just to if we could. continue to communicate that and say you know we understand we don't control the funding but if we have to make a decision the first thing on our agenda is you know our staff current staff well i appreciate that i think it could be messaging from staff i think the staff do appreciate it you can see a lot of sounds are engaged with and want to be with the board but maybe

Maybe in August, when you approve that budget that shows your level of advocacy and support of public health. So we could think about that as just a communication to the staff. You could maybe join one of our town halls, just share a message from the board or on behalf of the board of health and your support of staff. You've got to be huge because you all are visible at, you come to our picnics, you come to our all staff. But I think, uh, uh,

message from the board of health would be appreciated just to acknowledge they're doing good hard work every single day and that you support and advocate for us every day I have one more question about the are we encumbered by having a contract in hand but a delay of award and do we have levers to accommodate that

If I understand your question, so generally the state does not. Give us a contract until they have gotten their notice of award, but we have federal dollars. Don't we? We do not. Well, we have 1 federal grant and we actually don't, we don't notice the word until we, until the dollars are there. Perfect. So, and I hope to never having to chase down dollars that we are contractually. I'd love to hear that.

Storing. and CRI, at the moment, we are operating under a $0 extension. So the state does not have their notice of award. They expect their notice of award. And we are able to retroactively bill. So I mean, we're mostly sure we're going to get that money. But, you know, all told, this is like $650,000, $700,000 that we're operating with that at the moment.

And we're just pulling that out of our current coffers until we can build.

Five-year grant, they were able to do kind of the, this is part of a multi-year grant that we expect as long as it's signed in July. When the grant starts July 1st again, we expect, and as long as it's signed, then we can get the dollars beginning in July. And from an operating standpoint, we, since we're already on a reversible schedule, it's a non-issue at this point. If we get well down the road towards the end of our fiscal year, then we might have to do some truing up with the county as far as maybe looking at having to pull dollars from our fund balance. But from a cash standpoint, we don't have that issue.

So, love it. Thank you.

You're back. Okay, thank you.

Moving into the budget conversation. I just wanted to remind everyone of the timeline. This is set by the, we're kind of melding the statutory requirement for the board of health to approve a budget by September 1st, and then the county's budget process where they have to adopt a budget by December 15th. So we'll present the draft budget today with a heavy emphasis on draft. There's lots of conversations happening at the county level. We have gotten initial guidance, but we don't have final information like what the market and merit is going to be. We've incorporated assumptions and we'll go into those in this budget. But so there could be some changes. There could be significant changes to what presentation you receive in August for approval. So. We will review with Mark, the budget subcommittee in July, whatever new information we've gotten, if anything has changed and what we anticipate that to look like. And then in August, obviously you'll have the budget we're bringing forward for approval, which will be presented to the executive budget committee of the county in September. And so that's essentially the budget we are taking to the county.

And the correct, it really is our recommendation. I mean, it's the county commissioners that ultimately make the decision. So like a, Is it approval that's really the county commissioners on the final side?

Correct. And so in September, after that presentation, we will receive the executive budget committee's recommendations and that's what goes forward to the board of county commissioners for their approval. So far in all of our processes, the board of county commissioners has not come back to the EDC. So what we get as recommendations from them in September is generally what we can anticipate as our budget for December. All right, so I'm going to move into the priority requests that we're moving forward with with the county. And then after we go through those, we'll go through the total budget because there's a lot of moving pieces here. So our initial priority one ask is what we are calling WIC stabilization. And so WIC is our largest clinical-facing program. It sees 12,000 clients per month. since its inception, that program has been flat funded or slightly decreased. So when we're talking about that, it's a $2.6 million program. Last year we received a $61,000 reduction. So again, we were at the time, we were like, great, this is fantastic. We're okay. And when we look back, that trend has continued. So currently on that $2.6 million program, 93% of those expenses are staffing costs. And so it's a heavily staffed program. Again, reminding you that we're at 85 as a department. So in normal grant management process, we would right-size expenses to the total award. When we're looking at this by reducing expenses, that would be staffing. And so the funding formula for WIC is based on the previous year's caseload. if we were to reduce staffing we would be reducing the caseload therefore an out years reducing our funding so from a grant management standpoint it's not the correct choice um it would set us off into a spiral in the incorrect direction um and so what we have done so far throughout the year is we've been balancing the grant on the indirect rate that we collect and this year we are projecting collecting zero dollars in indirect on this program and it's our Our second largest grant, it's our largest clinical program. So that is why we've prioritized this request. And this request is to align us with other local public health departments within the region, actually within the state, in funding the WIC program managers, the WIC program leadership. So this is three, not new FTEs, but three positions that are already existing within the department. And we're asking for the general funding to support them.

We get funding, but none for administration or anything like that.

So moving to our second priority ask, this is a request for new FTE, but to expand the pilot program that we launched this year for our Family Connects. I technically launched last year, but full force this year. And so This is a universal home visiting program for parents of any baby born currently at Denver Health, and the request would allow us to expand to up to an additional 350 visits. And so it's for a full-time registered nurse and a part-time business support.

What does business support mean?

That would be like an administrative coordinator. In this case, Melissa can correct me if I get this wrong, It's to do follow-up on referrals and to make sure that there's not additional needs are unmet.

Okay.

Our third priority ask, if you remember from our budget request last year, we requested operating supplies for both our immunizations and sexual health clinics. And that's because neither one of these programs is fully grant-funded. and both have had reductions both last year and now again this year. Last year, the county was able to support us at $125,000 for each clinic. So a total of 250,000. It was one time dollars, but it's been very helpful to each clinic. And so the request is for this to become an ongoing support to each one of these clinics.

It's not for people though. Correct. It is very specifically not for people.

Our fourth priority is for an environmental health land use and built environment position. With this FTE, the department would be able to move from a reactive case review of land use reviews into a holistic environmental health and healthy communities planning and development process. So it would be taking work that both Steve and others within the department are already doing and expanding and helping to create capacity for some of the other members on the team as well.

So this would be a new FTE.

For our fifth priority request, this is harm reduction capacity. So as I've mentioned multiple times, our harm reduction program, they receive approximately five different grants, and I don't believe we've had one that has not had significant cuts in this program. And so what we are, it's similar to last year, if you remember, we requested the emergency preparedness manager. We are requesting the funding for the harm reduction supervisor to preserve the prevention, preserve the harm reduction program and the prevention work that's done case of continued cuts. So it's, again, not a new FTE, but it is additional funding.

But if you don't get it, it could potentially be a cut.

Yeah, so what we're looking at with that program right now is that they're essentially, we're shrinking the amount of supplies that the program is able to work with. So yes, we could be looking at difficult conversations on that program. Our sixth priority ask is an injury, violence, and prevention specialist. So the nursing team received a technical grant this year, or I'm sorry, a grant for technical assistance this year with the Safe States Alliance team. And as they've worked with that team, one of the recommendations that came out of it is it is best practice for the department to have this injury, violence, prevention specialist. it does align with other LPHAs in the region that do have similar positions. And the intention of this FTE would be to coordinate safety work, organize data and create partnerships. And again, this is a new FTE we are requesting. And the seventh priority request, the last request is for a rural outreach specialist. So with the changes to Medicaid and the access to food, our rural community of Arapahoe County has very unique needs that don't necessarily specifically align to what our targeted outreach is now. And so having a dedicated specialist that would be housed in the community would meet those, would be able to help coordinate and meet those needs.

And again, this is a new FTE. Okay.

Now we go into the really fun part of the conversation.

Really quick. How many of those requests do you think realistically?

It's going to be in the notes.

So what we have seen kind of trend-wise, I don't know if it's specific, but what we have seen is that approximately half of our requests are approved.

Do like the top, like the priority ones?

Correct. That's why we rank them. That is part of the budget process is to rank them priority.

And yes, they generally will choose our priorities. What is the process like for creating a priority list?

We started with, so last year during the 180 process, the director's team sat down and we went through all of the needs that we had. And it went from everything from very critical needs down to these would be really nice to have. And the county called it a must, should and could, I believe was the categories they put it into. And so for this year, we actually pulled that back out, and luckily we did because that was the guidance we got from them, and went back through it and said, what's changed? And last year, the WIC capacity was actually on there as well. It was at a lower dollar amount. So we started there, and then as we go through the year and gather more information, the priorities change. So WIC was not actually the first priority until we got to this part of the budgeting process. So we can talk through how we changed that, but That's how the priorities go, is we kind of look at, we being the directors and Jennifer and I and Penny, look at what the landscape looks like at this time.

I would also mention when we formed the budget subcommittee and Mark started working with us on budget and talking about it, he asked us about a risk matrix. And we didn't have one, so we put together what would be the risk of losing these funds at what level and what's the impact of that so that kind of helped the priority in thinking you know how why did we prioritize WIC the stabilization because the impact of that is great um and so that's how we use numbers but also the risk matrix and the impact to the community of not doing the thing we also have to look at you know what's mandated What do we absolutely have to do? And that's kind of how the county thinks is it mandated, which is hard for public health because really there are very few things that are mandated. It is, you know, we have to do a CHIP, a CHAH, child fatality review, and that's about it as mandates. Everything else is delegated or we're contracted to do it. But they are the things that we need to do and they align with the boards.

Of county commissioners priorities.

Okay, I'm actually going to start on the expense side, because that has driven a portion of the revenue piece. And so these are as a reminder projection. So we're utilizing assumptions that we have looking back. We're assuming I have had conversations with the county budget manager. And so what assumptions she's making? So we have built in a 4% merit and market increase to our salaries. Within the benefits line, there is the associated 4% increase in payroll taxes and the retirement contribution that the department makes on behalf of the employee, as well as that retirement contribution percentage is increasing also. So currently we are at 10%. I'm sorry, we're currently at 9.25%, we're going to 9.5% with the goal to be at 10% by 2030. So that will continue. That's a county thing. That's a county thing, correct. And then we're also anticipating medical benefit premium increase for the employer of 10%. And so that is, again, an increase we, as the department, will pay. And so those are built in here, that's what you see in the salary and benefits increases and that comes out to write about nine hundred thousand dollars, just a little bit over. And so then I'm going to move out now, I'm going to move up to the revenue side of this. So you'll see our decrease in. grants, projected grants. So some of this is the final trail end of ARPA funding that we had received in different pots. So we had received ELC funding, we had received FIG funding, and we'd received harm reduction expansion funding. And all of those were actually funded on the backside by ARPA funds to the state. And so those are done, and we do not have them incorporated into our budget for next year. So That's part of it. The other part is the grant cuts that we talked about earlier. So harm reduction program reductions, sexual health reductions, and immunization reductions, as well as some of the other smaller ones. So a projected $300,000 decrease in our grant funds. On the next line down, you're seeing the fee for service increase. A primary increase driver there is last year, if you'll remember, the retail food license fee renewals. In statute, they were finally able to pass uh a bill to increase those and it was incremental over three years so that's the next step of the increase we're anticipating um i'm going to jump over the public health fund balance until after the next point so then you'll see we have broken out our public health general fund so these are what we have asked the county for in various buckets and we're very intentional in the buckets that we track. So the first is ongoing. This is the baseline for when we opened our doors, the county gave us $6 million and that has been consistent. Then we have ongoing due to market and merit. The county set a policy, it's not really a policy, but a standard that they would fund our merit and market pool increase every year at 30%. And so that's what that is cumulatively. since essentially 24, when we received our first merit and market increase. And Tracy has a fabulous document that tracks each year and each increase. And then we have our ongoing budget asks. So this is the request for this year, the priority packages that we just reviewed. That is that number. And then the one-time request. So last year, if you remember, we made a verbal request during EBC for them to fully fund our total comp package. And they did, and we are going to make that a verbal request again. I am intentionally not putting that into the budget package requests right now, because if we put that in based on the total dollar amount, that will be all they fund. And so we would like to have a strategic conversation with them about how we change that model going forward. And I don't want to hamstring us into some of the other concerns we have that we would like to address in our budget process.

The way to change it is to say we need $7 million, not $6 million plus $908 million.

Correct. But I want to be able to... What did you say? Did you preview the slides? No.

I want to be very transparent in where all of those dollars are, and so that's why we broke it up.

One question on the expense side. In terms of the benefits, you mentioned that that's the employer portion. Is the county going to ask the employee to increase there?

We don't know yet.

Have they ever in the past? Last year, yes. Oh, they did. So the employee is paying more. Correct. And that potentially could happen again. Correct.

We have not gotten the renewal rates. At least we haven't been told what they are, and so we don't know what that looks like quite yet.

We haven't seen the total presentation and I don't think that will be until August. Yes. So, for our budgeting timeline, it's a challenge.

Hence why I said earlier, it's a heavy on the draft budget aspect here. So.

Okay, so then we get into the public health fund balance line. I have 1 other question. Do they the 908,000 do they do that for other departments? Like, no.

That was a very unique request. We are also in a unique position from a funding standpoint with the county. There's only two other departments that are as heavily grant funded as we are. And so it's just a different relationship. Most of the other departments are general funded. So when they're looking at their entire budget, it's a little bit easier. Granted, there's lots of paths they have it in, but it's a little bit easier for them to say, okay, now we just It just goes there because there's no other source of revenue. So that's why we want to have that strategic conversation with them about this looks different for us. And the landscape within grant funding has changed as well. So based on the increase in our expenses and how heavily we're increasing expenses on our salary side, We incorporated this year and anticipated need to actually utilize fund balance from. But the public health fund, so we have been putting into it every year and this year. I am projecting we will need to utilize it. There's some caveats to that. If we have any vacancy savings, that would reduce that number because all of this is based primarily on personnel. So, including it in this in the budget request would give.

department the authority to spend up to that amount out of fund balance if we were to need it so any questions there hard to balance the budget yes but i do want to make a comment about that there is this newer philosophy especially in the nonprofit world but we don't invest in ourselves so we expect every foundation takes 5% and they use that to fund community. And they also use that to pay for their own needs. Nonprofits tend not to do that. So in some ways that the fund balance is like a saying, well, we're going to fund, we're going to invest in ourselves with our savings or our investments. It's just a very new way of thinking because otherwise, if you take that out, you're running on a deficit and everyone hates seeing deficit. We, you know, so stressful for us and foundations used to also hate seeing a nonprofit line of deficit. And that has really changed. They know the climate has changed. So that's just another way to think about, you're just investing in the organization.

So this is just the visual representation of the revenue side.

Can I add one more thing for the conversion piece too? So this is a projection of really money that's not going to be put into the fund balance that the board had approved. So it's not pulling money out. It's not putting money in.

In this case, it is possibly pulling money out up to $471,000, almost $471,000.

I was thinking it was not the $471,000 that was put into the fund.

Yeah, it's possibly pulling out.

So sorry for the confusion.

No worries.

that would require board so generally generally yes we do need a board approval to utilize fund balance since we've incorporated in the budget we would have if if proved that we would have authority up to spend that to pull that out of fund balance i'm not working very loud no you're okay So this is the visual representation of the revenue totals and very heavily emphasizing the percentage. So when we opened, and I have another slide on this next, but when we opened the anticipated percentage of grant funding for the department was supposed to be 70%, and we're now projecting under funding historically even though it wouldn't be great increases it would be three or five percent enough to usually cover your benefits and salary increases or close to it at least and again we've historically been flat and again we will share that table once we put it together because I think it's going to really show the picture of what I've been trying to articulate and then the grant award landscape has changed the demand for grants. This just increased so much. We have a phenomenal team. We have written great grants in the past and been awarded. And this year we are not getting the awards. And so it's again, not for any lack of our team and no changes to our team. I mean, the people who are writing grants for the ones that were writing grants three years ago. And so it's just really speaking to that change in landscape.

And is it, and all ever possible. And maybe this is just a whole mindset change that we may have to look at the revenue side, the earning side more than we ever have. And that's, and we were having that discussion in terms of increasing. We're going to have to place even.

Sure.

Um, so this is a table to demonstrate where we, where our grant revenue has been as a percentage of our revenue. 23 through 25 are actuals obviously, 26 is still budgeted and then we're projecting 27 with what we have known at this point. 23 is slightly misrepresented because if you remember the board of county commissioners gave us a million dollar one time funds to start our fund balance. And so if you were to adjust that revenue as a total, it'd be about a 62% grant revenue versus total revenue. Which is still, we never have hit the 70% that they anticipated from the conception and we can see the steady decline. So. It's just, again, trying to visually demonstrate what we've been trying to articulate.

Why was it 70% who said it or who?

I believe it came from Tri-County.

Oh, Tri-County.

Tri-County was generally 70% grant fee and other contracts, 30% from the three counties. So that was how it was forever. And that's really how we planned the budget and how the counties approved what their contribution would be to Tri-County Health Department. So when we came over, it was a 70-30 split that had always been there. And the reality is, you know, without those economies of scale, it's not realistic, especially given the changes in the funding landscape. So that is what we're looking at and thinking about what does revenue look like.

not in just the short term, but the long term. And then the visual representation of our expenses.

I do want to call out one portion of this. It's something that Mark asks us about, and it's an intentional project we're working on at the moment. You'll see the little tiny community programs line. So these categories, salaries, benefits, supply services, they align with what we call our general ledger codes, and it's the granular what the expense is. Is it food? Is it mileage? Is it operating supplies? Things like that. And throughout the last three years, we've very intentionally been working on cleaning those up. And now we're in a final stage of identifying purchases and expenses that are very specifically for community programs. And an example of this would be, we have frequently are asked to provide emergency assistance. This year, it was in the form of hotels for an individual that needed emergency housing for a different situation. And it would be coded to that line now. And so it's an intentional pulling out the right expenses to add that clarity to our budget. So you're going to see that grow. It's not to say that we aren't supporting community. It's very much a very specific title that comes out of the accounting system. And we're going to start utilizing that intentionally.

So any other questions? And questions.

Okay, I'm going to not alone. You're not.

Like, a really exciting budget presentation. We've got all.

The other thing I would add is next.

Next month, Mark is meeting with the subcommittee. So, if any of any of the board members have any questions, they can meet with Mark or direct to Mark. Just saying my vote. When we get ready to vote, I've communicated to the board. I feel totally confident because Mark sits at the table represents us that whatever mark represents or recommends issues. We. What I agree to, because you've been very thorough on the committee and have communicated to the whole board to process and where you think we as a board should go. So thank you for your subcommittee. Yes.

No, I do appreciate that. I mean, I flagged, you know, for the budget subcommittee, the question on the revenue. Yeah. Some of the reasons I was really appreciative of the discussion on the fees and the good work that happened there, but we just saw, like, you know, that one table there where one has to assume, at least worst case, that the grant dollars are going to decrease and there really needs to be some hard conversations about how the revenue would be. Yeah. So we won't solve that now until in August, but I do think it's something long-term that just public health as a county and beyond need to grapple with.

And the programs that we're serving in those areas are for the most needy of our population. That's where we have to think. How do we do more with less? And it's unfortunate.

Any other comments? No. So we're going to move it to our second. Thank you.

You deserve some clapping.

Our second study question is an overview of retail food inspection and enforcement by Dillons and Josh.

Great, thank you.

Jennifer, how are we doing on time? We are doing good. Doing all right?

Yeah, so you've got five minutes. All right. But no more than that.

Because you all, Jennifer, thanks for the opportunity to speak. I appreciate it. Board, thanks for your time. What we wanted to do today is talk to you a little bit about a retail food inspection program and provide an enforcement overview when that enforcement is necessary. Give you all a general feel for how the process works. Okay. And as usual, if you have questions as I'm motoring through this, please don't hesitate to interrupt, raise your hand, just speak up. We'd be happy to address them. Here's what we have in store for you today. Quick review of where we get our authority with regards to retail food inspections, the purpose behind our inspections, a general landscape of our retail food process here in Arapahoe County. Our approach to inspections, our philosophy, the way we try to do things when interacting with operators, really want to give you a feel for that. Just some general inspection basics. What does it look like when a field staff walks into a kitchen? I won't go into great detail there, but I want to give you a general idea. What are our compliance rates in general? Give you a feel for what the state sees. I'll also give you a feel for what we see here in Arapahoe County to compare that a little bit. I'll turn things over to Josh, who is an expert where enforcement is concerned, and he'll share a couple slides on enforcement And we'll also follow up with those board of health responsibilities where enforcement's concerned as well. So that's what you have in store. All right, the next 45 minutes. So let's start with authority. This is a bit of a review, I would suspect, but the state health department derives its primary authority to establish a food protection program and set standards in the food protection act that's where it all starts everything's grounded in and of course you can read up and on all that in the colorado revised statute if you're interested um and then of course at the discretion of the state health department they can delegate this program to local health departments so there are a handful of delegated programs here at arapahoe county retail food being one of them So fortunately the state entrusts us to do retail food inspections on their behalf as established in a scope of work contract. So that's how that process generally works. And then of course, you know, the purpose here is to rate food regulations, establish minimum standards, protect the health and safety of the public. That's what we do.

Bill, do you know, do most counties have delegated authority? I know some really small ones.

Most of you, and there are some direct service counties that don't have the staff, budget, or personnel to actually do it. They contract with, and the state goes directly into those counties and conducts inspections for them.

Thank you.

Yeah. But, yeah, thankfully, we have the wonderful support of the board. We've got great staff. We can stand up a program and do inspections. Again, in close collaboration, stay healthy.

Yeah. Did we happen to get a copy? Me and Bebe were on the board the first year when they did the food regulations, the news ran a segment on our food regulators communicating to the public our approach. And a lot of the feedback I got was that was very helpful. because it showed that Arapahoe County is trying to work with owners in that. Because a lot of the perception is that, hey, they're coming in here basically with a negative. And it was like, no, our job is to partner with you. I just thought if any of the other board members haven't seen that video, they wasn't on the board at the time, but it was well received by the public. I got a lot of feedback for that.

Yeah. And I appreciate that comment. We'll talk a little bit more about that here in a minute. Really appreciate that. That really is what we try to do when we go into additional. So. Good question. All right, let's chat briefly about. what we're looking at here in Arapahoe County when we talk about retail food inspections. Just some general numbers to throw at you. If you look at the number of retail food establishments, and that's fancy speak for things like restaurants, also includes grocery stores and convenience stores. So, of course, we have our fancy acronyms, but yeah, a retail food establishment is primarily a restaurant, but also those grocery stores, convenience farms. So across the county, we have approximately 2,300 retail food establishments. That number is gradually ticking up each year. That's generally where we are. And if you break that down per staff member, when we are fully staffed, it's about 150 facilities per environmental specialist. which is right what the FDA is looking at. So we are on a sweet spot right now, which is fantastic. And because of the great training and the great work they're doing, we're really getting everything. So that just gives you a feel for the number of establishments that we're dealing with on a day-to-day basis. In addition to that, we license and inspect our mobile units. And last year, We licensed approximately 300 mobile units. So we do a renewal inspection to get them licensed. And then we try to do an operational inspection now in the field that are actually operating. Because bringing a unit in is one thing, but seeing in the field is something altogether. So approximately 300 mobile unit inspections. And that number is actually holding true this year again. So that's right about where we are.

Do you have to be licensed in each county to move your food truck around the state?

Good question. No, there is licensed reciprocity from mobile food units. And there was a bill that was passed last year that now allows reciprocity with the city and county of Denver. So the idea was to expand access for mobile operators so they can go wherever they want to go. So if they get a license here in Arapahoe County, they can go wherever they want. Now they're required to go to a commissary to get fresh water, do cleaning. If it's really far away, remind them to shoot. But yes, that one license is good. Good question. In addition to RFEs and mobile food unit, our staff also issued license for temporary food vendors. These are the food booths that you would see if you went to a weekend festival, a weekend celebration. Think Arapahoe County Fair, for example, right? They set up these temporary food booths and sell a wide range of foods. We do require a license for that as well. So last year we issued 169 temporary food licenses. spanning approximately 68 special events. So a lot of activity here in the county, which is great, right? This time of year especially, pick a weekend, there's an event pretty much, and we want to make sure they're licensed as well. Does that include small things like weddings? Good question. So weddings are private events, so we would not interfere with a private event. It needs to be a public-facing event. Abracadabra. I've got my slides here, so.

Can you get one temporary license per year?

Great question, yes. It's one temporary license per year, and that is how this is. Rebooting?

No, it's asking me if I'd like to.

Of course, restarting. So, yeah, we do require a license for calendar year and the special event license is specific to that county. So there's not reciprocity or that when it's considered.

So that's a big thing. We are back so no expect caterers for private events.

If it's a public-facing event, then we would have a caterer be licensed. But if it's going to a private event, then we don't. But the caterer is licensed. The caterer is licensed, correct. Yeah, absolutely. So we would go and inspect that. So if you crunch all of that, Looking back to 2025, our field staff conducted approximately 3,000 inspections. They're out in the field doing a lot of work, a lot of really good work. And that does include those re-inspections. I'll talk more about the difference between an inspection and a re-inspection here in a minute. But it includes the mobile units and those special events. So about 3,100 inspections over the course of 2021. I also wanted to mention that all the staff and consumer protection conducting these inspections go through an internal training process. And once they reach a certain point, they're expected to standardize with the state health department.

And this is really important because it ensures that you've So we do license hospitals. Yeah, so if they have food service there, then you'll get the license.

And move 6-1-1.

Oh, sorry. Yeah, it kind of depends on.

But, yes, we oversee some of that. I just did, and it still.

Can we take a two-minute recess? Will we reset this computer, please?

Just have a little chat. Tell your neighbors something nice. Okay, we'll add two minutes.

It wouldn't be a meeting if we didn't have tech issues.

I am like, wait, what's the one that keeps beeping at me? Okay. But I didn't insult you when I said that. Oh, no, no. Not at all. And then after that, we did have a train. Yes. On the move. So that wasn't you. Did you train us? Yeah. Yeah. Yeah.

Only the commissioners understood the rules. Right. It's happening.

Yes.

Yes. Yes. Yes. Yes. It's a long story.

Well, yes. Oh my gosh, yeah.

I love it. So brave again on this notice.

I'm going to try to see it again.

That's why I.

Yeah. Yeah. Yeah.

Thank you.

okay i know we're good actually we're back we're back on

Break is over.

Break is over.

Okay.

Our three-minute, five-minute break is nearly over.

We are back online. Great. Thanks. I'll jump right back in here. And I won't start from the top. I'm just going to wrap up the slide. The last bullet point there has to do with, since things need to be, all staff need to be in place. So in addition to the standardized piece, they take consistent ranges . I want to spend a little bit more time on this slide, if I might, because I think this is particularly . But what is our philosophy here at Arapahoe County, and what difference does this also from other ? On the one hand, we are charged with the built-in regulations. But on the other hand, we firmly believe that the path of compliance after the floor building lies in prioritizing integration. So if our operators can understand the whys behind the regulations, we say this a lot, but if they can, then we believe they're not going to like to comply, understand, and that partnership piece is strengthened. So we really make an effort to educate our operators when we go and do our routines. That's a big part of what we do. And emphasize that collaborative approach. How can we work with our operators to find solutions to that? What are some things that we can focus on together to find a way? The regulations are sort of set in stone, so to speak, but how can we personalize them both? And again, communicate with each individual operator to find a touch point with them to find solutions. And that's challenging, right? But it's very, very important. It really might be time to emphasize that collaboration piece and working with. Establishing rapport and building relationships. Hey, how's your business going? Hey, that's a picture of, is that your grandmother on the wall? Or maybe there's a statue on a shelf somewhere, right? And engaging with them like that. It goes a long way towards building rapport, learning who they are as people, and not just being a person with the regulations. Again, that's a lot of effort. It takes time, but it does make a big difference. We're going to try to teach that next step.

So how does the team approach sort of enforcement discretion? So I'm reading kind of bullets between, say, the second and the fourth, where maybe there's sort of a minor, if you will, more minor issue and kind of latitude to envision that. inspectors have, you know, otherwise they'll suddenly come back and visit with their supervisor on it about how to approach that and how to keep the consistency. Right.

If you're all for that discussion. Great question. Yeah. So we're going to get into a little bit more in a minute here. There's violations are assigned points. We'll talk about this in a second. And there's variations in how many points are assigned. So we're really trying to teach staff and critically about how pervasive is a violation and how many points do we want to assign. Okay. And, yes, we always encourage staff to contact their supervisor and discuss things. It seems like a bigger issue, right? Try to find that common ground. And not just need your assigned clients and assigned evaluations. Because at the end of the day, we want to find that rapport and go from class to office. Go back to the clients. Absolutely. Thank you. Yeah, that's a good question. Thanks. So that sort of gets into the next bullet there. Avoiding that mindset of just being picky and going through a kitchen and trying to find everything that's wrong. It's a thick book of regulations. And it's pretty easy to find things if you want to, by and large. But really, we're looking at what's important here. How can we work with the outbreak and deal with those bigger issues and resolve those issues? And of course, recognizing the value of entrepreneurship here in the county. People depend on these businesses for the life of it. That's not lost on us. Asking someone to throw away food is a big deal. be a lot of money for that um so really remembering that it's an integral part of our community and it's their livelihood in many respects we take that into consideration with each and every inspection um and this last piece again is also really important um embracing equity and promoting cultural awareness big county wide variety lots of languages lots of cultures which is also challenging, right? But how can we as inspectors embrace that and engage with that? And we really made an effort to try to inspect the support. At this point, I think we have 10 different languages that we use for our registration packets. We just did Hindi and Arabic, thanks to a lot of hard work that Kristen has done. So we try to provide information to our community. in their language as much as they can. Staff regularly use translation devices like the Language Line. Maybe from their Pocket Talk, they use that as well. Or just apps on their phone when they need to. Find a translator. How can we find a way to communicate and build a rapport with them? So we can really make an effort to do that. When's a good time to come for you? What would work for you? So all of those things are wrapped up in this picture of not just being a regulator, but being a navigator. And in many ways, being a navigator. So that's really how we started. Questions on that? All right. I'm going to spend a quick minute here and talk to you about what it looks like when our staff go into a kitchen and do an inspection. And I may tag team Josh in here because he's a true expert on this, but I want to give you just a quick overview of what the hydro inspection process looks like. So first thing I want to mention is that the system is established again by the state health department. So it's a uniform approach across the state. So it's not just Arapahoe County approaching this right. It's all people who are doing these stellar relief programs in the state of Colorado. When we talk about violations, what is it the staff are looking for? What I want to share is that violations are categorized by risk. So there's three different risk categories when it comes to a violation. There's what's called a priority violation, which is a little bit more concerning. You have a priority foundation violation, and then a quota violation, which is more sort of structural, building maintenance stuff, less food safety. And then what staff are asked to do is, when they're looking at these violations, they're asked to determine, well, what's the pervasiveness of that violation? So there is judgment built into the system, right? There's staff discretion. And Mark, to get to your question a little bit, we really try to be thoughtful about how many points we're assigning any given violation, you know, looking at pervasiveness. And that's where the flexibility or the subjectivity comes into play when we're doing this discussion. And one of sort of the metrics that we use is when determining pervasiveness, We ask, you know, how bad was this violation versus how bad could it have been? And then we can assign the place. So unless something is really, really bad, we're not going to try to go gangbusters and assign those places somehow. Again, it's really about protecting the public health. Finding a way to solve a concern. What's the meaning of points? Yeah, good. And that segues perfectly into that inspection outcome piece, right? So what happens is at the end of each inspection, the system tallies up the number of points a sucker, and there's three possible outcomes from any given inspection. If you have 49 or fewer points, you pass. Thanks for your good work. We'll see you next time. If you have 50 or up to 109 points, you need a re-inspection, which means we're going to be back in 10 days to do the same thing again. You did all right, but you could probably benefit from one for instance. If you have 110 points or more, which is a lot, we're going to ask you to close, temporarily close. And usually it's a day, two, three max. May seem like a lot, but I'll tell you that the Colorado Restaurant Association was strongly behind us. It allows us to deal with that very small minority of restaurants that just are posing an immediate public risk, right? So it allows us to close them on the spot. Again, open as soon as we possibly can. I'm going to show you some numbers here in a second, but again, closure is very difficult. Are these inspections announced? Do they know when they're coming? Typically not, although sometimes we will, right? Again, it's sort of a judgment call. Most restaurants, you know, we're not going to need to, but some benefit if they have a little bit of that. So as a general rule, we don't, but it is in balance. So we can use that periodically. Any questions on how violations work or inspection? I'll show you what this looks like. We zoom out and look at state numbers. And this is for fiscal year 2025. So, again, states on the fiscal year. My caveat is the data that we're looking at, is pulled from databases that are using the same platform the state is using for something called Healthspace. So I think there's 25 plus local public health departments that are using Healthspace, so that's the data. So it's not every health department in the state, but it's a large . So if you look at fiscal year 2025, the platforms that are using Healthspace conducted a total of almost 22,500 . with an average score of 22. All passing, right? Because 22 is a max, so less than . So if you split real close, you can see that less than 1% were closed. Small, small, small number. It's hard to close a restaurant. They have to be really performing poorly. The vast majority, statewide, upwards of 90% pass for inspection. They're doing great. We move on. We'll see you next time. And then there's a fraction of less than 10% that do require re-inspection. We come back in a few days, do it. Usually they pass the second. Takeaway here is, from a state perspective, closures are rare. Let's zoom in on a wrap of county numbers. In that same period in 2025, again, the fiscal year, the staff conducted 23, 2,350 closures. Our average score is slightly higher than the state average of 26 or 22, but very, very similar. Our numbers are actually very on par with state averages. You can see, again, that 86-ish percent mass inspection, that big green chunk. There is a small percentage that requires a re-inspection. And then very consistent with state numbers is that closure rate of less than 1%. So again, we don't close many kitchens, largely because, again, we're looking for ways to find solutions and keep them open and operating. But admittedly, there are rare instances kitchens would benefit from a closure. So any questions on this piece?

We're going to be having a discussion about restaurants. Possibly.

Possibly. Possibly.

And of the two that get closed in a year, one is fighting it? That's why we're having...

So we have issued a notice of hearing to address a situation with a restaurant that has been closed several times and we are looking at having a hearing for a potential revocation of their license.

Okay.

But it's one of the two that... That's the percentage, but yes, they've fallen extremely low.

Extremely low.

This gives you a feel for closures in general. These are facilities that are closed, but then reopened one or two days later because they've corrected a pervasive temperature issue. Perhaps there was a sewage backup. Perhaps there's a road in the infestation area. They say, oh, my gosh, yes, thank you. We corrected their back. This is another story. Where do most restaurants get deep? Temperature control. Temperature control is a big one, yeah. Especially around cold holding, keeping food cold. It's challenging. Especially this time of year. Understandably so, right? And that's where Brad's giving us the call. They've had a challenging inspection in the past. Rather than throw away all their food, hey, we're going to be coming out. I want to make sure that walk-in refrigerator that wasn't working last time is holding at 56 degrees is now working. Damage control and report building.

But if it wasn't working, they have to throw away all the food that was in there.

We will ask them to voluntarily discard food sometimes. Voluntarily discard. We don't do it ourselves. We ask them to do it. And if they don't, then we can embargo the food. In which case, it needs to be held until a decision is made about what to do with it. We try to avoid doing that at all costs.

Because you don't want them to cook it and serve it.

No. Temperature abused food, we don't want them to use it.

So then filling it away is the only option.

Or we do lab tests and we confirm that it's safe.

Oh, gosh. That's unfortunate.

Which is an expensive process, hardly ever done. But it's an option that's available to them.

It's a stronger .

How often are these inspections or does each restaurant get an inspection? In the annual? Typically once a year. Good question. Yeah. So it's based on sort of a risk-based algorithm. How much food are they serving? What type of food are they serving? How have they performed in the past? And the system determines the concedures. But typically it's once a year.

A lot of restaurants will take surplus food and give it away to agencies that provide food to people in need. Yep.

Is that food inspected? It would be inspected if we were out there doing a normal inspection, but we don't go out and inspect that on an individual basis per se. But if we were doing a routine inspection, we'd assume a way to inspect that food. But it's not like we do that specifically. Is there a way for the public, let's say I'm at a restaurant and I see a rat or something in the corner, I know that's extreme, but is there a way for me to report that? It's like on the website. It certainly is. Yeah, it's called a report at a CERN. You can either call our offices and, you know, either my or Angeline, happily take your complaint, and it will be assigned out. Or, yeah, on our website, there's a place to report it. And does that then spur, like, an inspection? It depends on the nature of the complaint, and it would be assigned to an inspector. They would do their due diligence and follow up. Complaints come in all shapes and sizes, some more credible than others, but they would certainly do the due diligence, absolutely, on every single bullet. And related, you may or may not be aware, but all our inspection results are available online. So folks are interested to see how any given kitchen is done, they can go online. That's kind of good.

Dylan, we've always been impressed, like in California, where you go to a restaurant and there's like a scorecard. I know the Colorado Restaurant Association has really, I seem to recall they fought that.

Pretty hard over the years, isn't it?

Where does that stand today? Or do we, as consumers, need to go to the Rappaport County and go find the details of that?

I know it's a great question. There's been a lot of discussion on that. And it's a fairly contentious topic. There's a lot involved there. And the state of Colorado made a deliberate decision not to use a grade system. Rather, it's a pass, which tells the public you're doing just fine. And So, you know, the vast majority of our restaurants passed. That's what they decided on. There's the re-inspection. Come back and see them. There's the closure of these. We don't post that. So if folks wanted to know how to do it, they need to go online or give us a call or do a quarter request or something. But, yeah, putting it in the window of the Restaurant Association was not. Understandably so. And online, how does one go about that? There's an inspection lookup link. on our website. And if you go there, you click on it, just type in the name of the restaurant and it'll pull up the inspection results.

A quick online search for Arapahoe County Health Inspections will yield that health inspection tool. And that goes for most metro health departments. Type in their county, followed by health inspection report, and you'll be able to find those links and access those rates.

Thank you. Good questions. Anything else?

This is like a silly question. Maybe go to a gas station and Bathroom is filthy, but they also have a hot dog machine. Is that you? It's us. It's us. It's us. It's us. It's us. It's us. It's us. It's us.

It's us.

We get no hot dogs with you, Christine.

Thank you for letting me know.

Before I officially turn it over to Josh, Josh, anything to add on this?

I think this will tie into the enforcement piece. What you're kind of seeing up on the screen with the graph really highlights the fact that most of our restaurants want to do well and they strive to do well, right? It's good business to do well. And our inspectors find that a lot of times too, which is why we get so much great education and voluntary compliance because operators, yeah, they care. They want to do well in very rare circumstances, do they not? And that's where I'm going to tap with the enforcement side of it. For those very few of my new percentage that really don't care, that's where we have the tools.

So with that, I'm going to segue over to Josh. And he's going to talk to you about enforcement again, Absolutely.

So speaking of tools in the toolbox, we like to think of this as the rusty hammer at the bottom of the toolbox, kind of a last resort, right? When we're doing enforcement, this is because all our other avenues and measures have failed us to gain compliance or change behaviors in a restaurant. This is not our starting point, but rather the point we have to take in order to protect public health, because we've been left with no other options. As you'd seen in the prior graph, you saw that sometimes we do closures for restaurants based on their ratings. If we're out there and they have a high percentage of points, meaning we have a wide variety of violations covering a multitude of topics, then we can suspend their license. And we'll talk about license suspension here in a moment. That's one reason we could initiate a closure. The other primary reason we typically run into is what we call imminent health hazards. where we will also temporarily suspend their license until we gain compliance or until they're in compliance to protect public health. A lot of these imminent health hazards make sense as kind of look through this list. If they don't have water, they can't wash their hands and wash dishes. If they have an ongoing outbreak, obviously we would want to stop that outbreak if it's ongoing and that would ensure further compliance with protecting public health. Massive pest infestations, fires that have led to chemical or smoke contamination of food or products, Lack of active managerial control, meaning it is just so out of control in there, they have a high amount of points that has led to a closure. That's what we would consider an imminent health hazard there. And grossly in sanitary conditions, you walk into the kitchen, you're like, oh, no, this is going to be a bad day. You guys can sometimes do that in sanitary conditions. So these are set forth in state statute, and these are uniformly applied across the state. So these are one of the reasons we would temporarily suspend their license. But again, these generally aren't permanent. It's generally, hey, correct this thing that we know uncorrected would make people sick. Once that's corrected, then we can begin operations and have another inspection soon to make sure everything else is addressed that needs to be. We also have the opportunity to issue civil penalties. These are generally for repeated offenses. Every time we issue a civil penalty, there has been a warning. We never issue a civil penalty first. There always is a warning first. This is outlined in state statute, but also it's a good approach. A lot of times what we're running into is folks may not know it was an issue. We told them that it was an issue. It generally doesn't happen again. So civil penalties are generally speaking not our first rule because generally they start with a warning. And in most cases, civil penalties that are issued are generally for those that are operating without a valid license and continue to not get licensed. Or it's renewal season when their license is due and they opted to try to forego getting a license. What I want to highlight here though, is for violations of the food code, the food code is what provides the basic safeguards for food safety. It's adopted by the state health department. We follow an FDA food code, so it's nationally recognized. In our jurisdiction, since our inception in 23, we've only issued seven civil penalties for violation of the food code. Because our team does such an excellent job of educating before regulation, but also because our operators care enough correct issues before it even gets to this point. So what does it take to get to that point to issue a civil penalty for violating the food code, the basic safeguard for public health? To put it simply, there's a four strikes rule that leads to a civil penalty. Essentially what this means, if a facility does not pass their inspection in four consecutive inspections in a row, or four out of their five most recent inspections, we can issue a civil penalty. basically four chances before the saving occurs. So that really strikes why we want to educate before we regulate, because regulating to this degree gets a little bit tough. And to that extent, we also have a limitation in state statute where we can't issue a civil penalty more than three times within a 12-month period. That makes it very clear that this is not a money generation for the state. And we abide by that, too. It definitely can't be. Of those seven civil penalties issued for violating the food code, Four of those have been for one time to each facility. It was a behavior control measure. It corrected that behavior. Three of them have been to one facility in particular. Again, this is one of those things where it's last ditch effort to try to gain control or to correct behavior before it escalates. In addition to these civil penalty remedies, we also increase our inspection frequency. If a facility has shown us that They need our time in there a lot more to provide training, to provide education, or to protect public health. We'll increase the frequency we conduct those inspections to ensure, hey, last time we didn't do so well, let's come back and see if we're doing better sooner, and also to help provide us a more holistic picture of the facility. When we conduct an inspection, it's generally seen as a snapshot in time, but as we're in there more and more, we can start to get a better idea of, is this a consistent issue that's ongoing? Was it a one-time thing, just a bad day? And that's what these civil penalties try to accomplish is holistically, how are we doing? And if it's poorly, then one might be issued. And again, this rarely happens because most people want to do very well. And as I mentioned previously, we can issue civil penalties for a a handful of other violations of state statutes, such as not having a license or not allowing an inspection to occur. It is outlined in state law that we conduct inspections when activity is present. It doesn't necessarily outline that those need to be scheduled, much to what Dylan referred to earlier. As far as our other enforcement measures we have, as Dylan alluded to, we can voluntarily request food to be condemned. That removes liability from us, helps ensure that we educate the operators to why we see food needed to be condemned, and is an educational moment for them to say, okay, yeah, I agree with the process. I understand why this might not be safe to serve to the community. But if all else fails, as again, as Dylan alluded to, we could put essentially a hold order on that food if they disagree with our assessment, and then we can, HAVE LATER TALKS TO DETERMINE IF THAT FOOD SHOULD BE DISCARDED, SEE IF THERE'S ANY OTHER ROUTE FOR POTENTIALLY RECONDITIONING OR SAVING THAT FOOD, AND IF ALL ELSE FAILS, CONDEMN IT. WE ALSO HAVE A TOOL IN OUR TOOL BOX CALLED A COMPLIANCE AGREEMENT. WE USUALLY TAKE THIS STEP BEFORE WE GET TO PENALTIES WHERE WE OUTLINE AN ONGOING AND REPEATING VIOLATION TO TRY TO GET CONTROL OF THAT MEASURE BEFORE IT KEEPS CONTINUING. SO I'M BRINGING UP COMPLIANCE AGREEMENTS HERE TO OUTLINE THAT OUR STAFF HAVE A variety of tools that take place, generally speaking, before a license suspension or before civil penalties take place. That's not our end goal. We want to change behavior, purposely practices, help them get on the best practice and build that partnership so they want to work with us going forward. Penalties and suspensions are sometimes antithetical to that, so we try to avoid those where possible. Now, what does this look like in reality when we need to step up from civil penalties? So I mentioned the fact that we can suspend licenses Generally, this is a temporary measure. In most cases, it's a temporary suspension until the issues have been corrected, and then we'll go back and open up that operation. In very limited circumstances, can we suspend punitively? One of those circumstances where we could suspend punitively is if they'd been issued a civil penalty for violating the food code. So multiple consecutive inspections where things aren't going well, we could issue a civil penalty and suspend their license for only up to three days punitively and no more than that. Generally, we look at doing both measures, but sometimes we'll look and see which measure might be more effective depending on the facility we're in. If they have a large operating budget, penalty is not going to have that much of a change of behavior versus if they have a small operating budget, it's a lot more impactful and concurred behavior. So we try to curb those depending on the facility that we see. And then additionally, with that license suspension, we can only typically suspend three times within a 12-month period as well. It's not always the case, but that's generally the practice we follow because when we see a civil penalty, we generally can see that it's not going to be able to suspend the license if needed to curb behavior.

I had a question. If you have... something is closed for these reasons in Radford County. Can these people just cross the line? Is there a database that says this operator, this manager, this whatever, shouldn't be doing business across the line even?

This is where having the states as the uniform applicator for the code comes in handy because we can oftentimes communicate that this does happen to the state or we work very well with our local counterparts.

But I mean, when you're... suspending a license, are you putting that in a database or someone in another county puts it in a database and before you go out and inspect, you look on that database and go, oh, this mobile unit has just crossed the line and trying to get to Arapahoe County because they couldn't get to Denver.

Yeah, so there's not a shared database throughout the entire state, so that does make it difficult. But that is why we're in good partnership with the local public agencies that surround us when that happens. And most of the time when we're suspending licenses in the event of poor food handling, they're usually brick and mortars that can't move. So it makes the enforcement a little bit easier. Mobile food trucks do pose that concern, which is why we communicate with our surrounding network partners. We don't have additional questions. Don't hesitate to interrupt as we're going through. The next step kind of our enforcement process is going to be license revocation. In our years here, we have not had to move for this prior to. I mean, this is really done when we've seen that behaviors cannot be corrected. Civil penalties have had no effect and license suspensions have been shrugged off. At this point, it's the only option we have for protecting the public. And when we're looking at license revocation, we would be looking to revoke a license that prevents them from preparing food at that facility, which would essentially stop their operation for all intents and purposes. When this is done, it usually requires, not usually, it does require a hearing to be done to protect the due process. It offers an opportunity for us to make a case as to why we are pursuing a revocation. but also offers an opportunity for the facility to make the case as to why they should keep their license. So this is a great part of our system and great part of our process to ensure that there's no overreach, but to ensure that things were handled fairly and squarely and within state statute as well. And in our cases, when we do have a license revocation that is needed, this hearing will be held before you as the board of directors for health. So again, haven't had to do this so far, but one potential number docket. And then a final measure that's in our toolbox that we use when revocation isn't necessarily apical is injunctions through county or district courts. These injunctions can be temporary or permanent, typically in joining an individual or a business from violating the Food Protection Act or the set of statutes that govern retail food. And these could be done in cases where there is an operator that's potentially operating without a valid license, chooses not to get a license, ignores the penalties that we have, and therefore our only course of correction is going to the courts to ensure hopefully getting a license and hopefully protecting public health. And if not, enjoining them from injuring public health. Those are the three final measures that we have in our toolbox, so to speak. Dylan, would you like to add anything to those questions from the Board of Health on these topics before we continue?

I guess I'm curious about timing. For license revocation, it's during that year of their licensure versus re-upping their license? Is that what I'm gathering?

If a facility already has a license, we would move to revoke that license. And that would be a permanent measure. That would mean they could not renew it. We would not allow them to renew it.

Does that address your question? So if there was an entity that was not performing well, we could not renew their license? I mean, if license revocation fills it's always impermanent? Like, do we not renew them and have them?

It's essentially a revocation. Okay. Yeah, so under the statutes, as long as they pay to renew, we're required to renew that license, unless we go through this due process hearing to not renew it. So it's essentially treated the same as a revocation.

It's still required.

Thank you.

Question, please. I'm sorry. I know we're running low on time, so maybe... It's a longer response. We'll talk about it at a later time. But think about, like, foodborne diseases, you know, tied back, maybe a lot of times it's, you know, macaroni and salad that gets made along those lines. But is there a process here where there's a foodborne illness investigation and it ties back for restaurants? And what is that also in the point in recruitment?

It would include us and it would include Melissa's group as well. When we're looking at outbreaks that are directly impacting food safety, we have that opportunity to suspend a license if we believe that it will stop that outbreak from continuing to make people sick. But generally, we don't look at our civil penalties as a measure to go back and find somebody sick. That's not the intent. That's not how they set their setup. And again, we would be required to issue a warning before we could. Most of the time when there's an outbreak, our main goal of investigating those is to stop the outbreak and prevent future ones from occurring.

Yeah, because we've got to suspend a license to something that we pick up a week later from an investigation, and maybe you do.

Yeah, I'll say a lot of people stopping from outbreaks are, we find out after the fact. And by the time, when we are investigating for an outbreak, both our communicable disease and environmental health staff go out together and do that together to have different,

viewpoints looking at the outbreak. And oftentimes the issue has already resolved and we're looking at an education and prevention for future.

All right.

And the final slide that takes us through the end here is just a quick slide that goes through Board of Health responsibilities and where it comes from, why you may get involved with some of these going forward. And most of this boils down to due process, essentially saying whenever we're taking an adverse action against the license outside of suspension, so this means revocation or refusal, we would need a hearing in order to allow us to make our case and allow the licensee to make their case as to why they should keep their license and why we would want to pull it or book it or refuse it as well. So this is covered in a few different statutes as to your authority as Board of Health for these hearings and where that comes from. Is that primarily in regards to due process to make sure that the case is heard? General questions, comments? Turn it over to Dylan.

Does the local authority be stronger than the state authority in these cases?

No. When we are looking at the Food Protection Act, it makes it so that it's uniform application by the state and dedicated to local public health to follow what the state health department has. So we can never have anything stronger. We can't make our own points arraying system. We can't go, we can't change the enforcement actions that you saw up here, because those are outlined in the state statute. Those are the abilities delegated to the state health department and therefore delegated for us to follow as an agency of the state. And establishing contracts, too.

Yeah. Thank you.

Good question.

Is the licensee an individual or a business entity?

Yes. It can be all of the above. LLCs and corporate things.

So a business entity could reorganize as a different entity and open up a business next door.

There's a perceived loophole within state statute that alludes to much to what you're saying. However, the state attorney general's office and CDPHE have both agreed that that is not going to be tolerated and that we can adequately refuse licensing if we believe that they're trying to escape enforcement. That's just two questions. We incorporate the docs. we look at those cases stringently to ensure that it doesn't happen because we don't want to repeat activity of what we just accomplished by sure to protect public health. Sure.

Monica, anything to add? The only thing that I was going to add was that if we do need to proceed with the hearing next month, it will be very similar to what you all did with the septic system, right? We internally have had a lot of conversation about what This hearing could look like and there's various options, but we think to just make it fair to the restaurant owner to keep it sort of an informal process. So it's still with the Board of Health and it wouldn't be the attorney essentially treating it like a trial. It will just essentially be like a presentation from staff and a request or recommendation from staff. then you would hear from the restaurant owner and ask any questions, engage in dialogue, and then ultimately make whatever decision you choose to proceed with it. So just letting you know that it'll be similar to what you've already done before.

Is it for sure that this is going to happen, or is your treatment correct? If you can't speak to that, that's fine.

Yeah, there's not a potential to correct per se. There is a potential that they voluntarily accepted their license or walked away from the business and it comes under a complete different ownership not to scapegoat the enforcement office or so they're like, I'm done. We don't want no more part of this. That is a potential that could negate the need for hearing. That's very much under consideration at this point, but it's not our goal. So it's kind of still open yet.

The restaurant is closed until the hearing and a final decision is made.

And it's not at a gas station? I was just going to put this box over here. Well, I was kidding. I mean, it's Friday. I was like, maybe it's Friday.

Martin, do you have any questions?

What sort of analysis is done in terms of looking at that 10%? In terms of opportunities for education outreach, either targeting for a restaurant type or a particular community, are there some efforts there to really kind of understand who and then targeting approaches for education outreach?

You know, good question. I like to think that tends to be all over the board. I would generally say that in most cases we see that happen for brand new restaurants that have seen us before. And so it unfortunately provides an opportunity to educate. We just didn't know. And then it kind of corrects itself. There are some other considerations within there, such as some restaurants tend to yo-yo. So they do poorly when we first show up. They know we're coming back for a re-inspection and then they pass. So it creates this effect of, yeah, we'll do good when you know you're coming, and we'll change back for old behavior. And generally speaking, that allows us to implement some of our other actions for corrections, such as compliance. Hey, we've noticed this trend keeps continuing. How do we address this one? As far as if we've done analysis, per se, of exactly what's the meaning to these. Is there a specific community or area where this keeps occurring? I haven't recognized a single town other than I would say it's sometimes our new facilities where we see the sport just because they didn't know. They get a chance to correct and then nothing comes of it because they learn.

Are your inspections always scheduled? Do they know that you're coming on a particular day?

Typically not scheduled. Sometimes they're scheduled if we think that would be a benefit to everyone involved, but typically not. Usually nine o'clock.

While we're talking about the retail food program, so I've talked a lot about the poll survey that we do with employees, but when we came as a new health department, we invested in Qualtrics to do customer experience engagement and surveys, as well as with the staff. And the food program is really good about asking their operators to submit comments to our customer engagement. And I just want to share a couple of the comments that we get from the restaurants. One was, inspector was very helpful and she's very knowledgeable about all the issues we had. We love it because it makes us better to serve our customers. Our inspector was very professional and knowledgeable. They took their time and wanted to see us operate. We all have coachable moment for learning too. Thank you and keep up the amazing work. And then one last one. The inspector came into my shop to do routine health inspection. This was the first health inspection I had done as a manager. And she was just wonderful, very friendly and no nonsense when it came to the health inspection itself. She took the time to answer all of my admittedly stupid questions, which I very much appreciated. So it just shows the relationship that they really, look to build um and i will say we've we've received i don't know how many lots of comments and they're all positive so it just they've done a great job of building rapport and as you remember when we first opened one of our my um not challenged but our charge for staff was get out there be seen and build trust and i think it goes a long way especially WITH RETAIL FOOD TO HAVE THAT KIND OF TRUST IS HUGE. SO KUDOS TO THE TEAM. GOOD JOB.

AND BE THERE NO OTHER BUSINESS BEFORE THIS BOARD, WE ARE ADJOURNED.

This is where, with our PI, how Sean and I work together. I will, if I could, I'll add more time to the August meeting to do my director's report from this month and August together. That's okay with you all. Okay, now you can. Okay.

Have fun.