Evergreen Academy Preschool

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

“Findings: Based on the State Compliance Officer’s observations, in the Cypress room, there was a soiled diaper container located on the floor in front of the bathroom stall.”

AAC R9-5-601.4. A licensee shall comply with the following physical plant requirements, as applicable: 4. Except as provided in subsection (5), when providing child care services for infants or children who require diapering, a diaper changing area that meets the requirements in R9-5-503 is available in each infant room or indoor activity area used by an enrolled infant or child who wears diapers or disposable training pants;

“Findings: Based on the State Compliance Officer’s observations, in the Cypress room, there were enrolled children present wearing diapers/pull-ups. The activity room lacks a licensed diaper changing area.”

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 State Compliance Officer’s observations, the attendance roster in the Cypress room indicated 10 enrolled children present. There were 9 enrolled children present.”

AAC R9-5-501.B.1. B. A licensee shall ensure that a staff member: 1. Supervises each enrolled child at all times;

“Findings: Based on staff interviews, it was determined that children have been observed pushing and "rough housing" on the playground and preschool classroom. Staff stated that the classroom has been challenging to manage at times, resulting in supervision issues.”

AAC R9-5-510.B.4. B. A licensee shall ensure that a staff member does not use or permit: 4. Punishment associated with eating, resting, sleeping, toileting, and withholding outdoor play;

“Findings: Based on staff interviews, it was determined that snacks provided by the parents determined as unhealthy were not provided to the enrolled children.”

AAC R9-5-308.B. B. A licensee shall maintain documentation of the insurance coverage required in subsection (A) on facility premises.

“Based on a a review facility records, the licensee lacked documentation of a current insurance certifciate.”

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.

“Based on a review of facility records, it was determined that the licensee lacked documentation of a a current fire inspection (performed by a fire Marshall or local fire department) and a gas inspection”

AAC R9-5-401.4. A licensee shall ensure that staff members meet the following qualifications for employment or volunteer service at a facility:4. An assistant teacher-caregiver is 16 years of age or older and provides the licensee with documentation of one of the following: a. Current and continuous enrollment in high school or a high school equivalency class; b. High school or high school equivalency diploma; c. Enrollment in vocational rehabilitation, as defined in A.R.S. § 23-501; d. Employment as a teacher-caregiver aide for 12 months; or e. Service as a volunteer in a child care facility for 12 months;

“Findings: Based on a review of personnel files, staff 2 and 4 lacked documentation of education requirements listed rule.”

AAC R9-5-501.C.1. C. A licensee shall ensure that a staff member: 1. Supervises each enrolled child at all times;

“Findings: Per allegation and based on the Compliance Officers observation and a review of video footage of an incident that occurred on 8/29/24, 2 enrolled children were wrestling over a toy behind a cabinet area where staff could not see the children. During the investigation, children were observed laying on cots in the 1-year-old classroom and in the preschool room behind bookshelves and tables. The children could not be seen and supervised by the staff in the classrooms.”

AAC R9-5-203.C. C. Except as provided in A.R.S. § 41-1758.03, a licensee shall ensure that each staff member, before starting date of employment or volunteer service, submits to the licensee a copy of the staff member’s valid fingerprint clearance card,front and back, issued under A.R.S. Title 41, Chapter 12, Article 3.1.

“Findings: Based on a review of personnel files, staff 4 lacked a personnel file on site. Staff 4 was able to show documentation of a fingerprint clearance card verification using the AZDPS website, but lacked a documentation of a clearance card on site.”

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: Per allegation and based on staff interviews and a review video footage of an incident that occurred on 8/29/24, the health and safety of enrolled children was placed at risk of harm when staff 2 was observed grabbing 2 children in an aggressive manner and roughly moving them away from a book shelf.”

AAC R9-5-510.B.1. B. A licensee shall ensure that a staff member does not use or permit: 1. A method of discipline that could cause harm to the health, safety, or welfare of an enrolled child;

“Findings: Per allegation and based on interviews with staff and a review of video footage of an incident that occurred on 8/29/24, a staff member used a method of discipline that could cause harm to a child when staff 2 grabbed toys out of the hands of two children who were fighting over a toy in an rough manner. Staff 2 was then observed grabbing the children abruptly and aggressively while moving them out of the play in area in response to their behavior.”

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 a review of personnel files, it was determined that staff 4 lacked a personnel file on site with the required documentation listed rule.”

AAC R9-5-512.F. F. A licensee shall ensure that:1. Each toilet room in a facility contains, within easy reach of enrolled children: a. Mounted toilet tissue; and b. Except as provided in subsection (G): i. A sink with running water; ii. Soap contained in a dispenser; and iii. Disposable, single-use paper towels in a mounted dispenser, or a mechanical air hand dryer; 2. Staff members wash their hands with soap and running water after toileting; 3. An enrolled child’s hands are washed with soap and running water after toileting; 4. Except for a cup or receptacle used only for water, food waste is stored in a covered container and the container is clean and lined with a plastic bag; 5. Food waste and other refuse is removed from the facility building at least once every 24 hours or more often as necessary to maintain a clean condition and avoid odors; 6. A staff member or an enrolled child does not draw water for human consumption from a toilet room handwashing sink; 7. Toys, materials, and equipment are maintained in a clean condition; 8. Plumbing fixtures are maintained in a clean and working condition; and 9. Chipped or cracked sinks and toilets are replaced or repaired.

“Findings: Based on an observation, trash, including food waste, was observed overflowing and on the ground around the trash receptacle on the upper outdoor area.”

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 an observation, an open space larger then 4 inches vertically and horizontally was observed in the southeast corner of the upper play area, accessible to enrolled children.”

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 a review of personnel files and an interview with staff 2 and the director, staff 1 took 2 children to the restroom area, unsupervised, and the staff member's personnel file lacked documentation of the education required in R9-5-401(3) to be a teacher-caregiver.”

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.

“Finding: Based on a review of activity area attendance rosters, the Compliance Officer observed that the preschool classroom attendance roster was not accurate. Enrolled children were observed entering and leaving the classroom next to the outdoor area and staff was not taking attendance of the children as they were entering and leaving the outdoor activity area. A staff was also observed yelling out the doorway a child's name when the child was entering the outdoor area to announce that the child was on the outdoor area, but the other staff on the outdoor area did not register on their attendance roster that the child was present.”

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 an observation, enrolled children were playing on a play structure that was installed without approval from the Department regarding the resilient surface in the fall zones of the outdoor equipment. A child was observed falling off the slide while the Compliance Officer was present. Staff attended to the enrolled child and the child appeared to be unharmed.”

AAC R9-5-501.A.19. A. A licensee shall ensure that:19. Except as provided in subsection (A)(20), the following are stored separate from food storage areas and are inaccessible to an enrolled child: a. All materials and chemicals labeled as a toxic or flammable substance; b. All substances that have a child warning label and may be a hazard to a child; and c. Lawn mowers, ladders, toilet brushes, plungers, and other facility equipment that may be a hazard to a child;

“Findings: Based on observation, there were 2 chemical bottles and an unopened energy drink on a cabinet and desk, accessible to enrolled children in the pre-K (Candelen) classroom.”

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 observation, Classrooms A and B lacked posted lesson plans for the current week.”

AAC R9-5-208.B. B. At least 30 calendar days before the date of an intended change in a facility’s service classification, space utilization, or licensed capacity, a licensee shall submit a written request for approval of the intended change to the Department that includes:1. The licensee’s name; 2. The facility’s name, street address, city, state, zip code, mailing address, and telephone number; 3. The name, telephone number, and fax number of a point of contact for the request; 4. The facility’s license number; 5. The type of change intended: a. Service classification, b. Space utilization, or c. Licensed capacity; 6. A narrative description of the intended change; and 7. The following additional information, as applicable: a. If the intended change affects individual rooms, the following information about each affected activity area, as applicable: i. Identification of the activity area, ii. Current and intended square footage, iii. Current and intended operating hours, iv. Current and intended service classification, v. Current and intended licensed capacity, and vi. Whether the activity area has or will have a diaper changing area; b. If the intended change is to increase licensed capacity, the square footage of the outdoor activity area; and c. If the intended change includes an alteration or addition to the physical plant of a licensed facility, the following, as applicable: i. If the facility is not located in a public school or if providing child care services to infants, one-year-old children, or two-year-old children in a facility located in a public school, the information required in R9-5-201(A)(5)(g) and (A)(5)(h) showing the intended change; or ii. If the facility is located in a public school and provides child care only for three-year-old, four-year-old, or five-year-old, or school-age children, a set of final construction drawings or a school map, including the information required in R9-5-201(5)(j) showing the intended change.

“Findings: Based on an interview with the director, 2 enrolled children used an unlicensed restroom, next to the gym area.”

AAC R9-5-501.A.15. A. A licensee shall ensure that:15. Except when an enrolled child is napping or sleeping, each room used by an enrolled child is maintained at a minimum of 30 foot candles of illumination;

“Findings: Based on an observation, the infant classroom lights were off during naptime and the CO was unable to identify if there were staff or infants in the classroom without using the light from the CO's tablet.”

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: Per allegation, interviews with staff, and review of the licensee's incident report, ice was present on the facility's outdoor area on 1/8/24 and an enrolled child fell while outside and suffered an injury to their face.”

AAC R9-5-301.D. D. A licensee shall ensure that the following individuals are allowed immediate access to facility premises during hours of operation: 1. A parent of an enrolled child or an individual designated in writing by the parent of an enrolled child; or 2. A representative of: a. The Department, b. The local health department, c. Arizona Department of Child Safety, or d. The local fire department or State Fire Marshal.

“Findings: Based on observation, the licensee added a card key system to the entry ways to the facility and the classrooms and the Compliance Officer and Compliance Officer Supervisor were unable to get immediate access to facility premises and a classroom during hours of operation. A doorbell is located at the entry way and Department staff were waiting for someone to open the front door for approximately 5 minutes at the beginning of the investigation and for several minutes to enter a classroom.”

AAC R9-5-208.B. B. At least 30 calendar days before the date of an intended change in a facility’s service classification, space utilization, or licensed capacity, a licensee shall submit a written request for approval of the intended change to the Department that includes:1. The licensee’s name; 2. The facility’s name, street address, city, state, zip code, mailing address, and telephone number; 3. The name, telephone number, and fax number of a point of contact for the request; 4. The facility’s license number; 5. The type of change intended: a. Service classification, b. Space utilization, or c. Licensed capacity; 6. A narrative description of the intended change; and 7. The following additional information, as applicable: a. If the intended change affects individual rooms, the following information about each affected activity area, as applicable: i. Identification of the activity area, ii. Current and intended square footage, iii. Current and intended operating hours, iv. Current and intended service classification, v. Current and intended licensed capacity, and vi. Whether the activity area has or will have a diaper changing area; b. If the intended change is to increase licensed capacity, the square footage of the outdoor activity area; and c. If the intended change includes an alteration or addition to the physical plant of a licensed facility, the following, as applicable: i. If the facility is not located in a public school or if providing child care services to infants, one-year-old children, or two-year-old children in a facility located in a public school, the information required in R9-5-201(A)(5)(g) and (A)(5)(h) showing the intended change; or ii. If the facility is located in a public school and provides child care only for three-year-old, four-year-old, or five-year-old, or school-age children, a set of final construction drawings or a school map, including the information required in R9-5-201(5)(j) showing the intended change.

“Findings: Based on an observation, an outdoor play structure was permanently installed on the toddler outdoor area and the Department lacked documentation of receiving a written request for approval of the intended change before the date of the change.”