Gethsemane Lutheran Church & School

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 were 2 trikes missing the plastic handle covers exposing sharp metal holes.”

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 observation, in Room 4, the following hazard was accessible to enrolled children: *There was a nickel size hole exposing drywall on the chalk wall.”

AAC R9-5-516.B.4. B. If prescription or nonprescription medications are administered, a licensee shall ensure that: 4. A staff member: a. Administers a prescription medication provided by a parent only from a container dispensed by a pharmacy; b. Administers a nonprescription medication provided by a parent for an enrolled child only from a container prepackaged and labeled for use by the manufacturer and labeled with the enrolled child’s name; c. Does not administer any medication that has been transferred from one container to another; and d. Does not administer a nonprescription medication to an enrolled child inconsistent with the instructions on the nonprescription medication’s label, unless the facility receives written authorization from the enrolled child’s health care provider.

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that Child #1’s non prescription medication lacked the original packaging and Child #3’s prescription medication lacked the original packaging and was dispensed as a two-pack but only 1 was present at the facility and a physicians authorization to separate was not present.”

AAC R9-5-516.B.3. B. If prescription or nonprescription medications are administered, a licensee shall ensure that: 3. A facility director, or a staff member designated in writing by the facility director, does not administer a medication to an enrolled child unless the facility receives written authorization signed by the enrolled child’s parent or health care provider that includes the: a. Name of the enrolled child; b. Type of the medication; c. Prescription number, if any; d. Instructions for administration specifying the: i. Dosage and route of administration; ii. If indicated, starting and ending dates of the dosage period; and iii. Times and frequency of administration; e. Reason for the medication; and f. Date of authorization; and

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that the following medications lacked the required information: Child #1: The end date and the times and frequency of administration of the medication for 1 medication and the route, prescription number and times and frequency for the 2nd medication. Child #2: The start and end date, prescription number and times and frequency of administration of the medication. Child #3: There was no form for 1 medication.”

AAC R9-5-501.A.18. A. A licensee shall ensure that: 18. 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 the Compliance Officer’s observation, in Room 6 and Gym toilet rooms, there was a plunger accessible to enrolled children.”

AAC R9-5-516.G. G. A licensee shall return all unused prescription and nonprescription medications to a parent when the medication prescription date has expired or the medication is no longer being administered to the enrolled child or dispose of the medication if unable to locate the enrolled child's parent after the child's disenrollment.

“Findings: Based on facility documentation and the Compliance Officer’s observation, it was determined that the prescription medication for Child #2 was expired (Expiration date: 1/14/26). The expired medication had not been returned to the parent.”

AAC R9-5-510.A.1. A. A staff member shall provide guidance to help children respond to difficult situations. To develop self-regulation, children should receive adult support that is individual to the child and adapts as the child develops internal controls. This process should include: 1. Forming a positive relationship with the child, which occurs when the adult spends time talking to the child, listening to the child, following the child’s lead, playing with the child, and responding to the child’s needs; 2. Base expectations on the child’s developmental level; 3. Establishing and being proactive in teaching and supporting children in learning simple rules; 4. Modifying the learning/play environment to support the child’s appropriate behavior; 5. Creating a predictable daily routine and schedule; 6. Modeling desired behavior; 7. Showing children positive alternatives; 8.Using deliberate redirection, the staff member should encourage the child to use appropriate behavior, and provide positive feedback when the child exhibits the behavior; 9. Individualized positive discipline strategies based on the individual needs of children, such as using a buddy system, individualized schedule, special break, or another applicable positive discipline strategy; and 10. If applicable, a licensee shall develop a written plan with the enrolled child's parent to provide individualized social and emotional intervention supports for the enrolled child that includes methods for understanding the enrolled child's behavior, and developing, adopting, and implementing a team-based positive behavior support plan.

“Findings: Per allegation, based on staff statements, facility documentation, and the Compliance Officers' observations, Child #1 received a scratch when Staff #1 intervened Child #1 from harming another enrolled child. During naptime Child #1 attempted to kick a child who was on their mat. Staff #1 reached and grabbed Child #1 at the shoulder to prevent the kick. As a result, Child #1 had a scratch on their collarbone. Staff stated: *Child #1 said no when it was time to take a nap. Child #1 then hit a child, stepped on a child, and was about to kick a third child when Staff #1 grabbed Child #1 to prevent it. *Child #1 did have a scratch; it was one line, and it was red. *Staff #1 told Child #1's mom that they scratched the child accidentally. *Staff #1 did scratch Child #1, while reaching for Child #1, before Child #1 kicked another child in the face. *Child #1's scratch was approximately 1 to 2 inches long, red and blood was raised to the surface. *Child #1's parent was contacted and shown the scratch when coming to the room.”

AAC R9-5-501.A.15. A. A licensee shall ensure that: 15. In rooms used for napping, the lighting must be dim during nap time to promote an atmosphere conducive to sleep but must be bright enought for supervision of children;

“Findings: Per allegation, based on the Compliance Officers' observations, in the 1-year-old and 2-year-old classrooms, the lighting during nap time was not bright enough for the supervision of enrolled sleeping children.”

AAC R9-5-514. E. E. A licensee shall post, near an activity area or a room's designated exit, a building evacuation plan that details the designated exits from the activity area or room and the facility.

“Findings: Based on the Compliance Officer’s observation, Classroom 7 and the MPR lacked a posted building evacuation plan that details the designated exits from the activity area and the facility.”

AAC R9-5-516.B.3. B. If prescription or nonprescription medications are administered, a licensee shall ensure that: 3. A facility director, or a staff member designated in writing by the facility director, does not administer a medication to an enrolled child unless the facility receives written authorization signed by the enrolled child’s parent or health care provider that includes the: a. Name of the enrolled child; b. Type of the medication; c. Prescription number, if any; d. Instructions for administration specifying the: i. Dosage and route of administration; ii. If indicated, starting and ending dates of the dosage period; and iii. Times and frequency of administration; e. Reason for the medication; and f. Date of authorization; and

“Findings: Based on facility documentation and the Compliance Officer’s observation, the medication for Child #1 lacked documentation of the times and frequency of the medication on the written authorization form.”

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 Classroom 6 there were 3 plastic bottles containing liquid, a blue plastic bottle, a plastic pizza, a blue handle, a plastic time and a plastic cup with a paint brush on the diaper changing surface.”

AAC R9-5-503.A.2. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: 2. A hand-washing sink next to the diaper changing surface for staff use when changing diapers and for washing an enrolled child during or after diapering that provides: a. Running water between 86° F and 110° F, b. Soap from a dispenser, and c. Single-use paper hand towels from a dispenser;

“Findings: Based on the Compliance Officer’s observation, in Classroom 1 and Classroom 2, the temperature of the diaper changing sink was 115° F., in Classroom 6 the temperature was 80° F rather than 86° F to 110° F. as required. ***Previously Cited 08/24/2023”

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 Compliance Officer's observations, in Classroom 6, the diaper changing container was next to the diaper changing table accessible to enrolled children.”

AAC R9-5-501.B.5. B. A licensee shall ensure that a staff member: 5. For enrolled children 12-months and older, except as provided in subsection (C), prepares, posts, and implements 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. If weather and air quality permit, 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 the Compliance Officer’s observation, the MPR, Play Space and Chapel lacked a current schedule of children's age-appropriate activities.”

AAC R9-5-501.A.20. A. A licensee shall ensure that: 20. Except when used as part of an activity, the following are stored in an area inaccessible to an enrolled child: a. Garden tools, such as a rake, trowel, and shovel; and b. Cleaning equipment and supplies, such as a mop and mop bucket.

“Findings: Based on the Compliance Officer’s observation, in Classroom 9, there was a vacuum next to the table accessible to enrolled children.”

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, Classroom 8 and the Play Space lacked a posted capacity. ***Previously Cited 08/24/2023”

AAC R9-5-203.E. E. If a staff member possesses a fingerprint clearance card that was issued before the staff member became a staff member at the facility, a licensee shall: 1. Contact the Department of Public Safety before the individual becomes a staff member to determine whether the fingerprint clearance card is valid; and 2. Document this determination, including the name of the staff member, the date of contact with the Department of Public Safety, and whether the fingerprint clearance card is valid.

“Findings: Based on facility documentation and the Compliance Officer's observations, it was determined that the files for Staff #1, Staff #2, and Staff #3 lacked documentation of validation through DPS for their Fingerprint Clearance Card. The fingerprint clearance cards were validated at the time of the inspection.”

AAC R9-5-514. E. E. A licensee shall post, near an activity area or a room's designated exit, a building evacuation plan that details the designated exits from the activity area or room and the facility.

“Findings: Based on the Compliance Officer’s observation, Classroom 7 and the MPR lacked a posted building evacuation plan that details the designated exits from the activity area and the facility.”

AAC R9-5-516.B.3. B. If prescription or nonprescription medications are administered, a licensee shall ensure that: 3. A facility director, or a staff member designated in writing by the facility director, does not administer a medication to an enrolled child unless the facility receives written authorization signed by the enrolled child’s parent or health care provider that includes the: a. Name of the enrolled child; b. Type of the medication; c. Prescription number, if any; d. Instructions for administration specifying the: i. Dosage and route of administration; ii. If indicated, starting and ending dates of the dosage period; and iii. Times and frequency of administration; e. Reason for the medication; and f. Date of authorization; and

“Findings: Based on facility documentation and the Compliance Officer’s observation, the medication for Child #1 lacked documentation of the times and frequency of the medication on the written authorization form.”

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 Classroom 6 there were 3 plastic bottles containing liquid, a blue plastic bottle, a plastic pizza, a blue handle, a plastic time and a plastic cup with a paint brush on the diaper changing surface.”

AAC R9-5-503.A.2. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: 2. A hand-washing sink next to the diaper changing surface for staff use when changing diapers and for washing an enrolled child during or after diapering that provides: a. Running water between 86° F and 110° F, b. Soap from a dispenser, and c. Single-use paper hand towels from a dispenser;

“Findings: Based on the Compliance Officer’s observation, in Classroom 1 and Classroom 2, the temperature of the diaper changing sink was 115° F., in Classroom 6 the temperature was 80° F rather than 86° F to 110° F. as required. ***Previously Cited 08/24/2023”

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 Compliance Officer's observations, in Classroom 6, the diaper changing container was next to the diaper changing table accessible to enrolled children.”

AAC R9-5-501.B.5. B. A licensee shall ensure that a staff member: 5. For enrolled children 12-months and older, except as provided in subsection (C), prepares, posts, and implements 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. If weather and air quality permit, 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 the Compliance Officer’s observation, the MPR, Play Space and Chapel lacked a current schedule of children's age-appropriate activities.”

AAC R9-5-501.A.20. A. A licensee shall ensure that: 20. Except when used as part of an activity, the following are stored in an area inaccessible to an enrolled child: a. Garden tools, such as a rake, trowel, and shovel; and b. Cleaning equipment and supplies, such as a mop and mop bucket.

“Findings: Based on the Compliance Officer’s observation, in Classroom 9, there was a vacuum next to the table accessible to enrolled children.”

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, Classroom 8 and the Play Space lacked a posted capacity. ***Previously Cited 08/24/2023”

AAC R9-5-203.E. E. If a staff member possesses a fingerprint clearance card that was issued before the staff member became a staff member at the facility, a licensee shall: 1. Contact the Department of Public Safety before the individual becomes a staff member to determine whether the fingerprint clearance card is valid; and 2. Document this determination, including the name of the staff member, the date of contact with the Department of Public Safety, and whether the fingerprint clearance card is valid.

“Findings: Based on facility documentation and the Compliance Officer's observations, it was determined that the files for Staff #1, Staff #2, and Staff #3 lacked documentation of validation through DPS for their Fingerprint Clearance Card. The fingerprint clearance cards were validated at the time of the inspection.”

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 observation, it was determined that 6 out of 15 enrolled children's attendance forms lacked the following information: Child #1, Child #2, Child #3, Child #4, Child #5, and Child #6: An admission and release signature (squiggle lines) for 08/19/2024.”

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 facility documentation and the Compliance Officer’s observation, it was determined that the file for Staff #4 lacked documentation of a copy of a valid fingerprint card. The fingerprint clearance card was validated through the DPS website during the time of the 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 facility documentation and the Compliance Officer’s observation, it was determined that Staff #1 and Staff #2 were assistant teacher-caregivers. Staff #1 and Staff #2 were not qualified as assistant teacher-caregivers because the staff files lacked documentation of high school diploma or high school equivalency, enrollment in high school or vocational rehabilitation, or employment as a teacher-caregiver aide or volunteer for 12 months.”

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 observation, in the outdoor activity area, the following hazard was accessible to enrolled children: *The little tykes playhouse had a 12-inch crack with several sharp edges at the structure's base.”

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 the Compliance Officer's observation, in the Gym, 5 outlets lacked a safety plug in an unused electrical outlet.”

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 3 out of 22 enrolled children's Emergency, Information, and Immunization Record cards reviewed lacked the following required information: Child #1: The name of the individual to be contacted in case of injury or sudden illness of the child. Child #2: The name and contact telephone number of the child’s health care provider and the name of the individual to be contacted in case of injury or sudden illness of the child. Child #3: The name, home address, city, state, zip code, and contact telephone number of the 2nd parent of the child.”