Elena Montessori School

AAC R9-5-605.B.16. B. A licensee shall ensure that: 16. The fire extinguisher required in subsection (A): a. Is serviced at least once every 12 months; and b. Has a tag attached to the fire extinguisher that specifies the date of the last servicing.

“Findings: Based on facility documentation and the Compliance Officer's observation, the fire extinguisher was last serviced in December 2023.”

AAC R9-5-603.B. B. 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 observation,in the outdoor activity area, there was a wooden table with raised wooden slats with exposed sharp wood located on the edges.”

AAC R9-5-515.B. B. If an enrolled child exhibits signs of illness or infestation at a facility, a licensee shall ensure that a staff member: 1. Immediately separates the enrolled child from other enrolled children, 2. Immediately notifies the enrolled child’s parent by telephone or other expeditious means to arrange for the enrolled child’s removal from the facility, and 3. Maintains documentation of the notification on facility premises for 12 months after the date of the notification.

“Findings: Based on facility documentation and the Compliance Officer's observation, the Licensee lacked documentation of an illness and injury log.”

AAC R9-5-514. A. A. A licensee shall ensure that there is a first aid kit on facility premises that contains first aid supplies in a quantity sufficient to meet the needs of the enrolled children including the following: 1. Sterile bandages including: a. Adhesive bandages of assorted sizes, b. Sterile gauze pads, and c. Sterile gauze rolls; 2. Antiseptic solution or sealed antiseptic wipes; 3. A pair of scissors; 4. Adhesive or self-adhering tape; 5. Single-use, non-porous gloves; and 6. Reclosable plastic bags of at least one-gallon size.

“Findings: Based on the Compliance Officer's observation, the first aid kit lacked scissors, sterile gauze rolls, and gloves.”

AAC R9-5-509.C.21. C. A licensee shall ensure that: 21. A refrigerator at the child care facility maintains a temperature of 41° F or below and a freezer maintains a temperature of 0° F or below, as shown by a thermometer kept in the refrigerator and in the freezer at all times;

“Findings: Based on the Compliance Officer's observation, the freezers and refrigerators and freezers in the following classrooms were not maintained at the required temperatures: Daisy Room: *Freezer 4° F Refrigerator 46° F Lillian's Room: *Refrigerator: 50° F Sunflower Room: *Lacked a thermometer in the refrigerator.”

AAC R9-5-503.A.1. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: 1. A nonabsorbent, sanitizable diaper changing surface that is: a. Seamless and smooth, and b. Kept clear of items not required for diaper changing;

“Findings: Based on the Compliance Officer's observation, in the Daisy room, there was a rag, a pair of shorts, and an iPad on the diaper changing table. There were also 4 holes on the diaper changing table surface.”

AAC R9-5-502.C.1.lk. C. A licensee shall ensure that: 1. A staff member providing child care services in an infant room: k. Obtains written, current, and dated dietary instructions from a parent or health care provider regarding the method of feeding and types of foods to be prepared or fed to an infant at the facility;

“Findings: Based on facility documentation and the Compliance Officer's observation, 2 of 4 infant feeding instructions were incomplete. Child #1: The feeding instructions were not specific to what foods the child is eating. Child #2: The feeding instructions lacked the amount of formula per feeding and a schedule for feeding times. The food list lacked a parent's signature.”

AAC R9-5-502.A.5.b. A. A licensee providing child care services for infants shall: 5. Develop, document, and implement tummy time policies and procedures that: b. Ensure a staff member who is supervising a non-crawling infant while the infant is flat on their stomach and on the floor: i. Is within reach of the infant; ii. Does not perform any other duties while supervising the infant; iii. Does not allow the use of pillows, comforters, sheepskins, stuffed toys, or other soft products in the same floor space as the infant; and iv. Does not allow any product specified in subsection (A)(5)(b)(iii) to be within reach of the infant;

“Findings: Based on the Compliance Officer's observation, in the infant room (Lillian's room), there was a boppy pillow on the floor accessible to enrolled infants.”

AAC R9-5-501.A.1. A. A licensee shall ensure that: 1. In addition to complying with the requirements in this Chapter, the health, safety, or welfare of an enrolled child is not placed at risk of harm;

“Findings: Based on the Compliance Officer's observation, the fire panel was in trouble mode.”

AAC R9-5-404.E. E. In addition to maintaining the required staff-to-children ratios, a licensee shall ensure that: 1. Staff members are present on facility premises to perform facility administration, food preparation, food service, and maintenance responsibilities; and 2. Facility maintenance does not depend on the work of enrolled children.

“Findings: Based on the Compliance Officers' observations, the facility lacked a staff member to assist with administrative duties. All the staff members were needed to meet the ratio requirements. *Previously cited- previous rule number -R9-5-404.D 9/24/2024”

AAC R9-5-401.3. A licensee shall ensure that staff members meet the following qualifications for employment or volunteer service at a facility: 3. A child educator is 18 years of age or older and provides the licensee with documentation of one of the following: a. Six months of child care experience if working with enrolled children five years old and younger, or three months of child care experience if working with school-aged children; and: i. A high school diploma or high school equivalency diploma; or ii. At least 12 credit hours from an accredited college or university, including at least six credit hours in early childhood, child development, or a closely-related field; b. Associate or bachelor degree from an accredited college or university in early childhood, child development, or a closely-related field; or c. N.A.C., C.D.A., or C.C.P. credential;

“Findings: Based on facility documentation and the Compliance Officers' observations, Staff #1 was a child educator on the playground with enrolled children, but was not qualified as a child educator because the staff file lacked the following: *Six months of child care experience if working with enrolled children five years old and younger, or three months of child care experience if working with school-aged children. *A high school diploma or high school equivalency diploma. *At least 12 credit hours from an accredited college or university, including at least six credit hours in early childhood, child development, or a closely-related field. *Associate or bachelor degree from an accredited college or university in early childhood, child development, or a closely-related field. *A N.A.C., C.D.A., or C.C.P. credential.”

AAC R9-5-306.A. A. A licensee shall: 1. Maintain a dated attendance form containing an enrolled child’s name with the time of each admission and release, and the parent or staff member's signature or other unique identifier. 2. If an electronic signature is used to admit or release the enrolled child, 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; 3. 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. 4. 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. 5. 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. 6. 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 observation, the licensee lacked documentation of the enrolled children's attendance records.”

AAC R9-5-301.I. I. At least once a month, and at different times of the day, a licensee shall ensure that: 1. An unannounced practice drill that includes evacuation, relocation, shelter-in place, and lock downs are conducted; 2. Each staff member, volunteer, and enrolled child at the facility participates in the practice drill; 3. If applicable, accommodations are made for an enrolled child with a special need or disability according to the enrolled child's individualized plan as specified in R9-5-507(A)(1); 4. If applicable, accommodations are made for an enrolled child or infant who is not yet walking; and 5. Document each practice drill and maintain the documentation on facility premises for 12 months after the date of the practice drill.

“Findings: Based on facility documentation and the Compliance Officer's observation, it was determined that the licensee lacked documentation of a fire drill log.”

AAC R9-5-301.B. B. A licensee shall ensure that a facility director: 1. Designates, in writing, an individual who meets the requirements of R9-5-401(2) to act on behalf of the facility director when the facility director is not present in the facility; 2. Supervises or assigns a child educator to supervise each staff member who does not meet the qualifications of R9-5-401(3); 3. Prepares a dated attendance record for each day and ensures that each staff member documents on the attendance record the time of each arrival and departure of the staff member; and 4. Maintains on the facility premises, the dated attendance record required in subsection (B)(3) for 12 months after the date on the attendance record.

“Findings: *Based on the Compliance Officers' observations, Staff #3 was alone and unsupervised by a qualified child educator on the playground with enrolled children. **Based on facility documentation and the Compliance Officers' observations, the Licensee lacked documentation of the staff members arrivals and departure times. *Previously cited- 9/24/2024”

AAC R9-5-203.G. G. As required by A.R.S. § 8-804, before an individual’s starting date of employment or volunteer service, a licensee shall comply with the submission requirements in A.R.S. § 8-804(C) for the individual.

“Findings: Based on facility documentation and the Compliance Officers' observation, it was determined that Staff #1 lacked documentation of a submitted Central Registry Background check. The Central Registry Background check for Staff #2( starting date of employment- 2/24/2025) was submitted after the starting date of employment, on 3/26/2025.”

AAC R9-5-306.B. B. A licensee shall: 1. Develop, document, and implement policies and procedures to ensure that a staff member maintains daily documentation of the presence of an enrolled child in an activity area that includes a method to account for any temporary absences of the enrolled child from the activity area, and 2. Maintain the documentation of the presence of enrolled children in an activity area required in subsection (B)(1) on facility premises for 12 months after the date of the documentation.

“Findings: Based on facility documentation and the Compliance Officer's observation, in the Lillian's classroom, there were 3 children on the roster, and there were 4 children present. The Daisy's class lacked a roster on the playground.”

AAC R9-5-508.C. C. If a licensee provides food, a licensee shall prepare and serve food according to the meal pattern requirements found in Table 5.1, "Meal Pattern Requirements for Children."

“Findings: Based on facility documentation and the Compliance Officer's observation, the yogurt was not specified on the menu for 9/6/2024,9/13/2024, and 9/27/2024.”

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 Officer's observations, the following hazards were observed on the facility playgrounds: *There was chipped paint with exposed rough wood located on the brown wooden flower box. *There was one trike that lacked black rubber on the wheel.”

AAC R9-5-603.E. E. A licensee shall ensure that the following is provided and maintained within the fall zones of swings and climbing equipment in an outdoor activity area:1. A shock-absorbing unitary surfacing material manufactured for such use in outdoor activity areas; or 2. A minimum depth of 6 inches of a non-hazardous, resilient material such as fine loose sand or wood chips.

“Findings: Based on the Compliance Officer’s observation, the outdoor activity area lacked the following resilient surfacing: *5 of the required 6 inches of pebbles in the fall zones of the green slide. *2 of the required 6 inches of pebbles in the fall zones of the yellow slide.”

AAC R9-5-605.B.10. B. A licensee shall ensure that:10. Toilet rooms are ventilated to the outside of the building, either by a screened window open to the outside air or by an exhaust fan and duct system that is operated when the toilet room is in use;

“Findings : Based on the Compliance Officer's observation, in the 2-year-old and 3-year-old toilet room, the exhaust fan was inoperable.”

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 observation, it was determined that 7 out of 11 enrolled children's Emergency, Information and Immunization Record cards reviewed lacked the following required information: Child #1 and Child #5: The child's home telephone number. Child #2: The contact number of the child's health care provider. Child #3: The date of the child's enrollment. child #4: The name of the individual to be contacted in case of injury or sudden illness of the child. The name, home address, city, state, zip code, and contact telephone number of each parent of the child. Child #6: The date of the child's enrollment. The contact number of the child's health care provider. The name of the individual to be contacted in case of injury or sudden illness of the child. Child #7: The child's home address. The contact number of the child's healthcare provider. 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.”

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 observation, the 1-year-old classroom and 2-year-old classroom lacked a posted capacity.”

AAC R9-5-302. A. A licensee shall prepare a written statement of child care services provided by the licensee that includes the following:1. A description of the facility’s child care services classifications in R9-5-204; 2. Hours of operation; 3. The facility’s street address, city, state, zip code, mailing address, and telephone number; 4. Child enrollment and disenrollment procedures; 5. Charges, fees, and payment requirements for child care services; 6. Child admission and release requirements; 7. Age-appropriate discipline guidelines and methods; 8. Transportation procedures; 9. Field trip requirements and procedures; 10. Responsibilities and participation of parents in facility activities; 11. A general description of activities and programs; 12. A description of the liability insurance required by R9-5-308 that is carried by the licensee and a statement that documentation of the liability insurance coverage is available for review on the facility premises; 13. Medication administration procedures; 14. Accident and emergency procedures; 15. A notice stating inspection reports are available on-site; 16. A provision stating that the facility is regulated by the Arizona Department of Health Services including the Department’s local street address, city, state, zip code, and local telephone number; 17. The procedures for notifying a parent at least 48 hours before a pesticide is applied on a facility’s premises; and 18. A statement that a parent has access to the areas on facility premises where the parent’s enrolled child is receiving child care services. B. A licensee shall provide a copy of the written statement of child care services: 1. To the Department: a. Before the facility receives a license, and b. Every 12 months after the date of the license as required by A.R.S. § 36-883.01; and 2. To a parent when the parent requests a copy of the written statement of child care services.

“Finding: Based on facility documentation and the Compliance Officer's observation, it was determined that the written statement of services lacked the following: -Hours of operation -The facilities street address, city, state, zip code, and mailing address -Refund statement -transportation procedures -field trip requirements and procedures -description of the liability insurance -a notice stating inspection reports are available onsite -a provision stating the facility is regulated by the Arizona Department of Health Services including the department's local street address, city, state, zip code, and telephone number -procedures for notifying a parent at least 48 hours before a pesticide is applied on a facility's premises -a statement that a parent has access to the areas on a facility premises where the parent's enrolled child is receiving childcare services”

AAC R9-5-301.B. B. A licensee shall ensure that a facility director: 1. Designates, in writing, an individual who meets the requirements of R9-5-401(2) to act on behalf of the facility director when the facility director is not present in the facility; 2. Supervises or assigns a teacher-caregiver to supervise each staff member who does not meet the qualifications of R9-5-401(3); 3. Prepares a dated attendance record for each day and ensures that each staff member documents on the attendance record the time of each arrival and departure of the staff member; and 4. Maintains on the facility premises, the dated attendance record required in subsection (B)(3) for 12 months after the date on the attendance record.

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that Staff #1 was a teacher-caregiver but was not qualified as a teacher-caregiver and was not supervised by a qualified staff member. Staff #1 lacked documentation of a high school diploma.”

AAC R9-5-404.D. D. A licensee shall ensure that a staff member assigned to provide child care services to enrolled children does not perform duties that may affect the staff member's ability to provide child care services to the enrolled children

“Findings: Based on the Compliance Officer's observation, Staff #2 was the facility director and a teacher caregiver.”

AAC R9-5-501.C.4. C. A licensee shall ensure that a staff member:4. Except as provided in subsection (D), prepares and posts in each indoor activity area, a current schedule of children’s age-appropriate activities, including the times the following are provided: a. Meals and snacks; b. Naps; c. Indoor activities; d. Outdoor or large muscle development activities; e. Quiet and active activities; f. Teacher-directed activities; g. Self-directed activities; h. Activities for individuals, groups of five or fewer children, and groups of six or more children; and i. Activities that develop small muscles;

“Findings: Based on facility documentation and the Compliance Officer's observation, the 1-year-old classroom lacked a posted activity schedule.”

AAC R9-5-403.C. C. A licensee shall ensure that documentation of a staff member's completion of training required by subsection (A) is signed by the facility director and dated.

“Findings: Based on facility documentation and the Compliance Officer's observation the 10-day training for Staff #1 lacked a date and signature by the director.”

AAC R9-5-401.2. A licensee shall ensure that staff members meet the following qualifications for employment or volunteer service at a facility:2. A facility director’s designee is 21 years of age or older and provides the licensee with documentation of one of the following: a. At least 12 months of child care experience, a high school or high school equivalency diploma, and: i. Three credit hours or more in early childhood, child development, or a closely-related field from an accredited college or university, or ii. At least 30 actual hours of instruction, provided in conferences, seminars, lectures, or workshops in early childhood, child development, or a closely-related field; b. At least 12 months of child care experience and: i. An N.A.C., C.D.A., or C.C.P. credential; or ii At least 24 credit hours from an accredited college or university, including at least six credit hours in early childhood, child development, or a closely-related field; c. At least six months of child care experience and an associate degree from an accredited college or university in early childhood, child development, or a closely-related field; or d. At least three months of child care experience and a bachelor degree from an accredited college or university in early childhood, child development, or a closely-related field;

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that Staff #1 was the director designee but was not qualified to be the director designee because the staff file lacked documentation of a high school diploma or high school equivalency diploma.”

AAC R9-5-309.C. C. A licensee shall maintain on facility premises: 1. A current fire inspection report including documentation of any repairs or corrections required by the fire inspection report; and 2. If there are gas pipes that run from a gas meter to an appliance or location on the facility premises, a current gas inspection report including documentation of any repairs or corrections required by the gas inspection report.

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that the Licensee lacked documentation of a current violation-free fire inspection report as required.”

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 facility documentation and the Compliance Officer's observation, the 1-year-old classroom lacked a lesson plan and the lesson plan in the 2-year-old classroom lacked a date.”

AAC R9-5-509.A. A. A licensee that prepares food for enrolled children on facility premises shall, if required by 9 A.A.C. 8, Article 1, andthe local ordinances of the local health department where the facility is located, obtain a food establishment permit issued under 9 A.A.C. 8, Article 1, and: 1. Provide the Department with a copy of the facility’s food establishment permit before the Department issues a license to the facility, 2. Maintain the facility’s current food establishment permit on the facility’s premises, and 3 Provide a copy of the facility’s current food establishment permit to the Department upon request.

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that the licensee lacked documentation of a current Sanitation inspection report as required.”

AAC R9-5-404.C.3. C. A licensee shall ensure that: 3. When six or more enrolled children are present in a facility, an infant is not placed for supervision with a child who is not an infant.

“Findings: Based on the Compliance Officer's observation, 6 or more enrolled children were present at the facility when 2 one-year-old children were placed in the Infant room with 2 infants.”

AAC R9-5-404.E. E. In addition to maintaining the required staff-to-children ratios, a licensee shall ensure that: 1. Staff members are present on facility premises to perform facility administration, food preparation, food service, and maintenance responsibilities; and 2. Facility maintenance does not depend on the work of enrolled children.

“Based on the Compliance Officers' observations, Staff #1 was the director, but was acting in the capacity of a Teacher-Caregiver at the time of the investigation. Staff #1 was unable to open the door for the Compliance Officer, and no other staff was available for administrative duties.”

AAC R9-5-209.A. A. A licensee shall allow the Department immediate access to all areas of the facility affecting the health, safety, or welfare of an enrolled child or to which an enrolled child has access during hours of operation.

“Findings: Based on the Compliance Officers' observations, the Licensee did not allow the department immediate access during the hours of operation.”

AAC R9-5-503.A.1. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: 1. A nonabsorbent, sanitizable diaper changing surface that is: a. Seamless and smooth, and b. Kept clear of items not required for diaper changing;

“Findings: Based on Compliance Officer's (CO) observations, in the Infant Room, the diaper changing surface had unsealed gaps at each end and open gaps on the sides. The table had cloth basket storage under the surface which is absorbent and non-sanitizable.”

AAC R9-5-503.E. E. A licensee shall ensure that the written diaper changing procedure in subsection (D) states that an enrolled child’s diaper is changed as soon as it is soiled, and that a staff member, when diapering: 1. Uses a separate washcloth and towel only once for each enrolled child; 2. Washes and dries the enrolled child using the enrolled child’s individual personal products labeled with the enrolled child’s name; 3. Uses single-use non-porous gloves; 4. Washes the staff member’s own hands with soap and running water between 86° F and 110° F before and after each diaper change; 5. Washes each enrolled child’s hands with soap and running water between 86° F and 110° F after each diaper change; 6. Cleans, sanitizes, and dries the diaper changing surface following each diaper change; and 7. Uses single-use paper towels from a dispenser to dry the diaper changing surface or the hands of the enrolled child or staff member.

“Findings: Based on CO's observations and a review of facility documentation, in Room 2, the diaper changing area lacked posted procedures.”

AAC R9-5-509.C.23. C. A licensee shall ensure that: 23. A freezer at the child care facility maintains a temperature of 0° F or below, as shown by a thermometer kept in the freezer at all times; and

“Findings: Based on CO's observations, in the Infant room, the freezer used to store enrolled children's food, lacked a thermometer.”

AAC R9-5-601.6. A licensee shall comply with the following physical plant requirements: 6. A glass mirror, window, or other glass surface that is located within 36 inches of the floor is made of safety glass that has been manufactured, fabricated, or treated to prevent the glass from shattering or flying when struck or broken, or is shielded by a barrier to prevent impact by or physical injury to an enrolled child.

“Findings: Based on CO's observations, between Room 1 and Room 2, there was a door with glass panels below 36" that lacked a safety glass seal or documentation verifying that it was safety glass.”

AAC R9-5-503.F.1. F. A licensee shall ensure that in an activity area with a diaper changing area: 1. The containers required in subsections (A)(3) and (4) are inaccessible, and

“Findings: Based on CO's observations, in the Infant room, the soiled diaper container was accessible, located in a cloth hamper basket next to the diaper changing sink.”

AAC R9-5-509.C.22. C. A licensee shall ensure that: 22. A refrigerator at the child care facility maintains a temperature of 41° F or below, as shown by a thermometer kept in the refrigerator at all times;

“Findings: Based on CO's observations, in the Infant room, the refrigerator used to store enrolled children's food, lacked a thermometer.”