B.E.S.D.#31 - Orangedale Early Learning Center

AAC R9-5-203.A. A. A licensee shall ensure that a staff member completes, signs, dates, and submits to the licensee, before the staff member’s starting date of employment or volunteer service: 1. The form required in A.R.S. § 36-883.02(C); and 2. If required by A.R.S. § 8-804, the form in A.R.S. § 8-804(I).

“Findings: Based on the Compliance Officer's review of staff files, the files for Staff #1 (DOE 7/1/2009) and #2 (DOE 7/23/2013) lacked documentation of the staff's DCS application and DCS clearance results.”

AAC R9-5-303.B. B. A licensee shall ensure that the licensed capacity of each indoor activity area or room is posted in that activity area or room.

“Findings: Based on the Compliance Officer's observations, the licensed capacity of Rooms #105 and #107 is 20, but was incorrectly posted as 30.”

AAC R9-5-304.B. B. Except as required in A.R.S. § 36-3009, before an enrolled child receives child care services, a licensee shall require the enrolled child’s parent to complete an Emergency, Information, and Immunization Record that is no more than a two-page written notice, and is signed by the enrolled child’s parent containing: 1. The child’s name, home address, sex, and date of birth; 2. The date of the child’s enrollment; 3. The name, home address, email address, and telephone number of each parent of the child; 4. The name and contact telephone number of at least two individuals authorized by the child’s parent to collect the child from the facility in case of emergency, or if the child’s parent cannot be contacted; 5. The name and contact telephone number of the child’s health care provider; 6. The written authorization for emergency medical care of the enrolled child when the parent cannot be contacted at the time of the emergency; 7. The name of the individual to be contacted in case of injury or sudden illness of the child; 8. The written instructions of a child’s parent or health care provider for the nutritional and dietary needs of the child including, if applicable, the request in R9-5-509(C)(14); and 9. A written record completed by the child’s parent or health care provider noting the child’s susceptibility to illness, physical conditions of which a staff member should be aware, and any individual requirements for health maintenance.

“Findings: Based on the Compliance Officer's review of Child Emergency and Information cards, the following Child Cards lacked information: *Child 1-The name of the individual to be contacted in case of injury or sudden illness of the child; *Children 2 and 3 - The phone number of the child's health care provider; *Child 4 - The name of the individual to be contacted in case of injury or sudden illness of the child and the phone number of the child's health care provider.”

AAC R9-5-514. C. C. A licensee shall: 1. Prepare and date a written fire and emergency plan that contains: a. The location of the first aid kit; b. The names of staff members who have adult and pediatric first aid and CPR certification, as required by R9-5-403(E); c. The directions for: i. Initiating verbal notification of an enrolled child’s parent by telephone or other equally expeditious means within 30 minutes of a fire or emergency; and ii. Providing written notification to the enrolled child’s parent within 24 hours; and d. The facility’s street address and the emergency telephone numbers for the local fire department, police department, ambulance service, and poison control center; e. The procedures for evacuation, relocation, shelter-in-place and lockdown, staff and volunteer emergency preparedness training and practice drills, communication and reunification with families, continuity of operations, and accommodation of infants, children with disabilities, and children with chronic medical conditions, as specified in R9-5-301; 2. Maintain the plan required in subsection (C)(1) in a location on facility premises that has an operable telephone service or two-way voice communication system that connects the facility with an individual who has direct access to an in-and-out operable telephone service; 3. Post the plan required in subsection (C)(1) in any indoor activity area that does not have an operable telephone service or two-way voice communication system that connects the indoor activity area with an individual who has direct access to an in-and-out operable telephone services; and 4. Update the plan in subsection (C)(1) every 12 months after the date of initial preparation of the plan or when any information changes.

“Findings: Based on the Compliance Officer's observations, the posted emergency plan was dated 10/2024 and had not been updated within the last 12 months.”

AAC R9-5-605.B.9. B. A licensee shall ensure that: 9. Fans are mounted and inaccessible to an enrolled child;

“Findings: Based on the Compliance Officer's observations, an unmounted oscillating tower fan was observed on the floor in Room 105 and was accessible to children.”

AAC R9-5-303.A. A. A licensee shall post in a place that can be conspicuously viewed by individuals entering or leaving the facility or activity area, the: 1. Facility’s license; 2. Name of the facility director; 3. Name of the individual designated to act on behalf of the facility director when the facility director is not present in the facility, as prescribed by R9-5-301(B)(1); 4. Schedule of child care services fees and policy for refunding fees as prescribed by A.R.S. § 36-882(P); 5. Breakfast, lunch, dinner, and snack menus for each calendar week at the beginning of the calendar week; 6. Notice of the presence of any communicable disease or infestation listed in 9 A.A.C. 6, Article 2, Table 2.2, from the date of discovery through the incubation period of the communicable disease or infestation; 7. Notice of the Department’s intent to deny, revoke, or suspend as prescribed by A.R.S. § 36-888 at the expiration of time in the notice for the licensee to respond; 8. Notice of an intermediate sanction imposed as prescribed by A.R.S. § 36-891.01 within 10 calendar days after the licensee received notice of the intermediate sanction; 9. Notice of a legal injunction imposed as prescribed by A.R.S. § 36-886.01 when the licensee receives the legal injunction; and 10. Notice of the availability of facility inspection reports for public viewing at the facility premises.

“Findings: Based on the Compliance Officer's observation, the posting board lacked the current lunch menu and the AM and PM snack menus.”

AAC R9-5-605.B.6. B. A licensee shall ensure that: 6. Except for a room used only for an enrolled school-age child, each unused electrical outlet is covered with a safety plug cover or insert;

“Findings: Based on Compliance Officers’ observations, 4 unused electrical outlets on the charging tower in Room 107 were not covered with a safety plug or insert.”

AAC R9-5-512.D. D. A licensee shall ensure that toilet bowls, lavatory fixtures, and floors in toilet rooms and kitchens are cleaned and sanitized as often as necessary to maintain them in a clean and sanitized condition or at least once every 24 hours.

“Findings: Based on Compliance Officer #1's observations, there was dried urine on the base of the toilet in the bathroom of Room 107.”

AAC R9-5-512.B. B. A licensee shall maintain facility premises and furnishings:1. In a clean condition, and 2. Free from odor.

“Findings: Based on the Compliance Officers' observations, the following areas were not maintained in a clean condition: 1) The wooden stairs in the bathroom of Room 105 had a build-up of dirt and brown smudges; 2)A pungent odor of urine in the bathroom of Room 107; 3) The corner of the diapering table in Room 107 had a build-up of dirt and sand in one corner of the table; and 4) 9 plastic containers of diapers were stored on an open shelf in the bathroom of Room 107.”

AAC R9-5-508.B. B. A licensee shall serve the following meals or snacks to an enrolled child present at a facility for the following periods of time:1. If an enrolled child is present two to four hours, one or more snacks; 2. If an enrolled child is present during any of the meal times stated in subsection (A), a meal that meets the meal pattern requirements in subsection (C); 3. If an enrolled child is present four to eight hours, one or more snacks and a meal; 4. If an enrolled child is present nine or more hours, two snacks and one or more meals; and 5. Before bedtime, one snack.

“Findings: Based on Compliance Officers’ observations and a discussion with the Director, the Director stated the children attend the PM program for 3 hours, from 12:30-3:30 PM. The director acknowledged that a snack was not served to the children during the PM program.”

AAC R9-5-501.C.5. C. A licensee shall ensure that a staff member:5. Except as provided in subsection (D), prepares and posts a dated lesson plan in each indoor activity area for each calendar week, which is maintained on facility premises for 12 months after the lesson plan date and provides opportunities for each child to: a. Gain a positive self-concept; b. Develop and practice social skills; c. Think, reason, question, and experiment; d. Acquire language skills; e. Develop physical coordination skills; f. Participate in structured large muscle physical activity; g. Develop habits that meet health, safety, and nutritional needs; h. Express creativity; i. Learn to respect cultural diversity of children and staff; j. Learn self-help skills; and k. Develop a sense of responsibility and independence;

“Findings: Based on Compliance Officers’ observations, Rooms 105 and 107 lacked a posted lesson plan.”

AAC R9-5-306.A. A. A licensee shall maintain a dated attendance form containing an enrolled child’s name with the time of each admission and release of the enrolled child. 1. Except as provided in subsection (A)(2), a licensee shall ensure that the attendance form is signed with at least a first initial of an individual’s first name and the individual’s last name by each enrolled child’s parent or individual designated by the enrolled child’s parent, each time the enrolled child is admitted or released. 2. An electronic fingerprint verification or an electronic signature may be used in place of a signature of the enrolled child’s parent or designated individual to admit or release the enrolled child. 3. If an electronic signature is used to admit or release the enrolled child, the licensee shall adopt policies and procedures to ensure that the individual whose signature the electronic or digital method of identification represents is accountable for the use of the electronic or digital method; 4. A licensee shall develop, document, and implement policies and procedures to ensure that the identity of an individual is known to the staff member or is verified with picture identification before releasing an enrolled child to the individual. 5. A licensee shall not release the enrolled child to an individual other than the enrolled child’s parent or other individual designated in writing by the enrolled child’s parent except when the enrolled child’s parent is unable to collect the enrolled child and authorizes the licensee by telephone to release the enrolled child to an individual not so designated. a. The licensee shall verify the telephone authorization using a means of verification that has been agreed upon between the licensee and the enrolled child’s parent at the time of enrollment. b. The licensee shall document the means of verification in subsection (A)(5)(a) on the enrolled child’s Emergency, Information, and Immunization Record card. 6. A licensee shall not permit the self-admission or self-release of an enrolled child unless the enrolled child is of school age and the licensee has obtained and verified written permission from the enrolled child’s parent. 7. A licensee shall maintain the attendance form on facility premises for 12 months after the date of attendance.

“Findings: Based on Compliance Officer #2’s observations and the facility documentation 4 out of 10 children’s attendance records reviewed lacked the following information: *Child #11: 02/03/25- A release signature; 02/04/25 - An admission time and signature; *Child #12: 01/30/25 The admission signature lacked the individual’s last name; *Child #13: 01/17/25 The admission time and signature and release signature; and *Child #14: 01/09/25 The admission signature lacked the individual’s last name; 01/21/25 The admission signature.”

AAC R9-5-304.B. B. Except as required in A.R.S. § 36-3009, before an enrolled child receives child care services, a licensee shall require the enrolled child’s parent to complete a Department-provided Emergency, Information, and Immunization Record card that is signed by the enrolled child’s parent containing: 1. The child’s name, home address, city, state, zip code, home telephone number, sex, and date of birth; 2. The date of the child’s enrollment; 3. The name, home address, city, state, zip code, and contact telephone number of each parent of the child; 4. The name and contact telephone number of at least two individuals authorized by the child’s parent to collect the child from the facility in case of emergency, or if the child’s parent cannot be contacted; 5. The name and contact telephone number of the child’s health care provider; 6. The written authorization for emergency medical care of the enrolled child when the parent cannot be contacted at the time of the emergency; 7. The name of the individual to be contacted in case of injury or sudden illness of the child; 8. The written instructions of a child’s parent or health care provider for nutritional and dietary needs of the child including, if applicable, the request in R9-5-509(C)(9); and 9. A written record completed by the child’s parent or health care provider noting the child’s susceptibility to illness, physical conditions of which a staff member should be aware, and any individual requirements for health maintenance.

“Findings: Based on Compliance Officer #2’s review of Children Emergency cards, 8 out of 10 Emergency Cards cards reviewed lacked the following required information: *Child #1- the person to call first in case of emergency, the child’s health care provider’s phone number and the written instructions of a child’s parent or health care provider for nutritional and dietary needs of the child and the date of the signature of the parent; *Children #2 and #4 - the person to call first in case of an emergency; *Child #5- the city and zip code of the child’s home address; *Child #6-the health care provider's phone number; and *Children #8, #9 and #10- the person to be called first in case of an emergency.”

AAC R9-5-303.A. A. A licensee shall post in a place that can be conspicuously viewed by individuals entering or leaving the facility or activity area, the:1. Facility’s license; 2. Name of the facility director; 3. Name of the individual designated to act on behalf of the facility director when the facility director is not present in the facility, as prescribed by R9-5-301(B)(1); 4. Schedule of child care services fees and policy for refunding fees as prescribed by A.R.S. § 36-882(P); 5. Breakfast, lunch, dinner, and snack menus for each calendar week at the beginning of the calendar week; 6. Notice of the presence of any communicable disease or infestation listed in 9 A.A.C. 6, Article 2, Table 2, from the date of discovery through the incubation period of the communicable disease or infestation; 7. Notice of the Department’s intent to deny, revoke, or suspend as prescribed by A.R.S. § 36-888 at the expiration of time in the notice for the licensee to respond; 8. Notice of an intermediate sanction imposed as prescribed by A.R.S. § 36-891.01 within 10 calendar days after the licensee received notice of the intermediate sanction; 9. Notice of a legal injunction imposed as prescribed by A.R.S. § 36-886.01 when the licensee receives the legal injunction; and 10. Notice of the availability of facility inspection reports for public viewing at the facility premises.

“Findings: Based on Compliance officers' observations, the parent posting board lacked the AM and PM snack menus and the lunch menu.”

AAC R9-5-603.C. C. Except as provided in subsection (D), a licensee shall ensure that an outdoor activity area:1. Is enclosed by a fence: a. A minimum of 4 feet high; b. Secured to the ground; and c. With either vertical or horizontal open spaces on the fence or gate that do not exceed 4.0 inches; 2. Is maintained free from hazards, such as exposed concrete footings and broken toys; and 3. Has gates that are kept closed while an enrolled child is in the outdoor activity area

“Findings: Based on Compliance Officers’ observations, the following hazards were observed on the preschool playground: *The bottom of 3 of the metal fence posts on the North side of the fence had areas of rust and the metal was sharp in these areas.”

AAC R9-5-605.B.9. B. A licensee shall ensure that: 9. Fans are mounted and inaccessible to an enrolled child;

“Findings: Based on the Compliance Officer's observation, in Room A105, there was an unmounted black and white tower fan located on the floor, accessible to enrolled children.”

AAC R9-5-509.C.14. C. A licensee shall ensure that:14. Each staff member is informed of a modified diet prescribed for an enrolled child by the child’s parent or health care provider, and the modified diet is posted in the kitchen and in the child’s activity area;

“Findings: Based on facility documentation and the Compliance Officer's observation, room A107 lacked a modified diet posted in the activity area.”

AAC R9-5-509.C.18. C. A licensee shall ensure that:18. A staff member: a. Prepares a weekly menu at least one week in advance, b. Includes on the menu the specific foods to be served on each day, c. Dates each menu, d. Posts each menu at least one day before the first meal on the menu will be served, and e. Writes food substitutions on a posted menu no later than the morning of the day of meal service;

“Findings: Based on the Compliance Officer’s observation, the menu lacked the specific type/flavor of cheese and steam mixed vegetables to be served to enrolled children.”

AAC R9-5-304.B. B. Except as required in A.R.S. § 36-3009, before an enrolled child receives child care services, a licensee shall require the enrolled child’s parent to complete a Department-provided Emergency, Information, and Immunization Record card that is signed by the enrolled child’s parent containing: 1. The child’s name, home address, city, state, zip code, home telephone number, sex, and date of birth; 2. The date of the child’s enrollment; 3. The name, home address, city, state, zip code, and contact telephone number of each parent of the child; 4. The name and contact telephone number of at least two individuals authorized by the child’s parent to collect the child from the facility in case of emergency, or if the child’s parent cannot be contacted; 5. The name and contact telephone number of the child’s health care provider; 6. The written authorization for emergency medical care of the enrolled child when the parent cannot be contacted at the time of the emergency; 7. The name of the individual to be contacted in case of injury or sudden illness of the child; 8. The written instructions of a child’s parent or health care provider for nutritional and dietary needs of the child including, if applicable, the request in R9-5-509(C)(9); and 9. A written record completed by the child’s parent or health care provider noting the child’s susceptibility to illness, physical conditions of which a staff member should be aware, and any individual requirements for health maintenance.

“Findings: Based on facility documentation and the Compliance Officer's observations, 4 out of 10 enrolled children's Emergency Information and Immunization Record Cards reviewed lacked the following required information: Child #1 & Child #7: The name of the person to contact in case of sudden injury/illness. Child #2: A second emergency contact name and phone number. Child #8: A second emergency contact name and phone number, and the health care provider phone number.”

AAC R9-5-203.F. F. A licensee shall ensure that each staff member submits to the licensee a copy of the staff member’s valid:1. Background check document issued under A.R.S. § 46-811(A) within 10 working days after starting date of employment or volunteer service; and 2. Background check document each time a background check is issued or renewed every five years.

“Findings: Based on facility documentation and the Compliance Officer's observations of 5 staff files, Staff #2's file lacked documentation of the DCS Registry Background check.”

AAC R9-5-402.A. A. A licensee shall maintain a file for each staff member containing:1. The staff member’s name, date of birth, home address, and telephone number; 2. The staff member’s starting date of employment or volunteer service; 3. The staff member’s ending date of employment or volunteer service, if applicable; 4. The name and telephone number of an individual to be notified in case of an emergency; 5. The staff member’s written statement attesting to current immunity against measles, rubella, diphtheria, mumps, and pertussis; 6. The form required in A.R.S. § 36-883.02(C); 7. Documents required by R9-5-203; 8. Documents required by R9-5-301; 9. Documents required by R9-5-401, if applicable; 10. If applicable: a. The form required in A.R.S. § 8-804(I), b. Documentation of the submission required in A.R.S. § 8-804 and the information received as a result of the submission, and c. Documentation of training provided by a licensee as required by R9-5-403, if applicable; 11. A copy of any current license or certification required by A.R.S. Title 36, Chapter 7.1, Article 1. or this Chapter; and 12. Documentation of the requirements in A.R.S. § 36-883.02(D).

“Findings: Based on facility documentation and the Compliance Officer's observations of 5 staff files, 1 out of 5 staff files reviewed lacked the following required information: Staff #1 (start date 4/26/2022): A negative Mantoux TB test. Reference R9-5-301.F.”

AAC R9-5-512.B. B. A licensee shall maintain facility premises and furnishings:1. In a clean condition, and 2. Free from odor.

“Findings: Based on the Compliance Officer's observation, in Room A105, there was a 1/4" gap in the Formica behind the sink, and the counter was not sanitizable.”

AAC R9-5-512.C. C. A licensee shall ensure that floor coverings are:1. Clean; and 2. Free from: a. Dampness, b. Odors, and c. Hazards.

“Findings: Based on the Compliance Officer's observation, in Room A105, there were discolored stains on the carpet.”

AAC R9-5-512.D. D. A licensee shall ensure that toilet bowls, lavatory fixtures, and floors in toilet rooms and kitchens are cleaned and sanitized as often as necessary to maintain them in a clean and sanitized condition or at least once every 24 hours.

“Findings: Based on the Compliance Officer's observation, in the toiler room in A105, there was a pink potty chair on the floor to the left of the toilet.”

AAC R9-5-603.C. C. Except as provided in subsection (D), a licensee shall ensure that an outdoor activity area:1. Is enclosed by a fence: a. A minimum of 4 feet high; b. Secured to the ground; and c. With either vertical or horizontal open spaces on the fence or gate that do not exceed 4.0 inches; 2. Is maintained free from hazards, such as exposed concrete footings and broken toys; and 3. Has gates that are kept closed while an enrolled child is in the outdoor activity area

“Findings: Based on the Compliance Officer's observations in the outdoor activity area, the following hazards were accessible to enrolled children: *There was rust on the safety gate pole. *There was rust on 2 wrought-iron fence posts. *There were spider webs below the Lakeshore sink play set.”

AAC R9-5-501.A.12. A. A licensee shall ensure that: 12. The facility premises, including the buildings, are maintained free from hazards;

“Findings: Based on the Compliance Officer's observations, the following hazards were accessible to enrolled children: Room A105: *There was an air purifier located on a low counter. *The metal cabinet near the entry door was unsecured and wobbled. (The wheel was missing from the front left leg.) Room A107: There was an air purifier on a low counter.”

AAC R9-5-501.C.9. C. A licensee shall ensure that a staff member:9. Does the following when a parent permits or asks a staff member to apply personal products on an enrolled child, such as petroleum jelly, diaper rash ointments, sun screen or sun block preparations, toothpaste, and baby diapering preparations: a. Obtains the enrolled child’s personal products from the enrolled child’s parent or, if the licensee provides the personal products for use by the enrolled child, obtains written approval for use of the products from the enrolled child’s parent; b. Labels the personal products with the enrolled child’s name; and c. Keeps the personal products inaccessible to enrolled children;

“Findings: Based on the Compliance Officer's observation, in Room A107 there were 2 unlabeled containers of diaper wipes that were not labeled with a child's first and last name, as required.”

AAC R9-5-306.A. A. A licensee shall maintain a dated attendance form containing an enrolled child’s name with the time of each admission and release of the enrolled child. 1. Except as provided in subsection (A)(2), a licensee shall ensure that the attendance form is signed with at least a first initial of an individual’s first name and the individual’s last name by each enrolled child’s parent or individual designated by the enrolled child’s parent, each time the enrolled child is admitted or released. 2. An electronic fingerprint verification or an electronic signature may be used in place of a signature of the enrolled child’s parent or designated individual to admit or release the enrolled child. 3. If an electronic signature is used to admit or release the enrolled child, the licensee shall adopt policies and procedures to ensure that the individual whose signature the electronic or digital method of identification represents is accountable for the use of the electronic or digital method; 4. A licensee shall develop, document, and implement policies and procedures to ensure that the identity of an individual is known to the staff member or is verified with picture identification before releasing an enrolled child to the individual. 5. A licensee shall not release the enrolled child to an individual other than the enrolled child’s parent or other individual designated in writing by the enrolled child’s parent except when the enrolled child’s parent is unable to collect the enrolled child and authorizes the licensee by telephone to release the enrolled child to an individual not so designated. a. The licensee shall verify the telephone authorization using a means of verification that has been agreed upon between the licensee and the enrolled child’s parent at the time of enrollment. b. The licensee shall document the means of verification in subsection (A)(5)(a) on the enrolled child’s Emergency, Information, and Immunization Record card. 6. A licensee shall not permit the self-admission or self-release of an enrolled child unless the enrolled child is of school age and the licensee has obtained and verified written permission from the enrolled child’s parent. 7. A licensee shall maintain the attendance form on facility premises for 12 months after the date of attendance.

“Findings: Based on facility documentation and the Compliance Officer's observations, 6 out of 10 enrolled children's attendance forms reviewed lacked the following required information: Child #1 & Child #2: Complete arrival and release signatures during the month of March, 2024. Child #3: Complete release signatures on 3/1, 3/21, 3/22, 3/25, 3/26, 3/28, & 4/2/2024, and complete arrival signatures on 3/25 & 3/28/2024. Child #4: A complete release signature on 3/1/2024. Child #5: Complete arrival signatures on 3/25 & 3/26/2024, and a complete release signature on 4/2/2024. Child #6: Complete arrival and release signatures on 3/25/2024, and complete release signatures on 3/21, 3/22, 3/26, & 4/2/2024.”

AAC R9-5-403.B. B. A licensee shall ensure that:1. Each staff member who provides child care services completes 18 or more actual hours of training every 12 months after the effective date of this Chapter or the staff member’s starting date of employment or volunteer service in at least two topics listed in this subsection: a. Child growth and development, including: i. Infant growth and development, which may include sudden infant death syndrome prevention; ii. Developmental psychology; iii. Language development; iv. Observation and child assessment; v. Developmentally-appropriate activities; vi. Child guidance and methods of discipline which may include training on the appropriate techniques to prevent a child from harm or to prevent the child from harming others; and vii. Developmentally-appropriate activity areas; b. Health and safety issues, including: i. Accident and emergency procedures, including CPR and first aid for infants and children; ii. Recognition of signs of illness and infestation; iii. Nutrition and developmentally-appropriate eating habits; iv. Child abuse detection, reporting, and prevention; v. Safety of indoor and outdoor activity areas; and vi. Sun safety policies and procedures; c. Program administration, planning, development, or management; and d. Availability of community services and resources, including those available to children with special needs; and 2. As part of the required 18 hours of training in subsection (B)(1): a. A staff member who has less than 12 months of child care experience before the staff member’s starting date, completes at least 12 hours in one or more of the topics in subsection (B)(1)(a) in the staff member’s first 12 months at the facility; b. A staff member who has 12 months or more of child care experience, completes at least 6 hours in one or more of the topics in subsection (B)(1)(a) every 12 months after the staff member’s starting date; c. A staff member who provides child care services to an infant completes at least 6 hours in subsection (B)(1)(a)(i) every 12 months after the staff member’s starting date; and d. A facility director completes at least 6 hours in subsection (B)(1)(c) every 12 months after the facility director’s starting date.

“Findings: Based on facility documentation and the Compliance Officer's observations, Staff #3's (start date 9/29/2022) file lacked 9.5 of the required 18 hours of annual training from 9/29/2022 - 9/29/2023.”