K.E.S.D.#28 - Kyrene Kids Club - Sierra

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 observations, the First Aid kit lacked the following required items: *Sterile gauze pads. *Sterile gauze rolls. *A pair of scissors. *Adhesive or self-adhering tape. * Single-use, non-porous gloves. *Reclosable plastic bags of at least one-gallon size.”

AAC R9-5-512.F.8.9. F. A licensee shall ensure that: 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 the Compliance Officer's observations, the toilet in the classroom restroom was not maintained in a repaired condition; there was a water leak at the base of the toilet.”

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 observations, the restroom was not maintained in a clean and sanitized condition; there was a brown grime buildup at the base of the toilet, a curtain separating the toilet area from the sink, and an accumulation of dust in the exhaust fan.”

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 observations, the room floors were not maintained in a clean condition, and there were brown grime stains and a buildup of sand on the carpet and tile floor.”

AAC R9-5-512.A. A. A licensee shall maintain facility premises free of insects and vermin.

“Findings: Based on the Compliance Officer's observations, there were ants in the restroom around the toilet base.”

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, and the 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. Submit to the Department a written notice 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 written notice of the facility’s current food establishment permit to the Department upon request.

“Findings: Based on the Compliance Officer's observations and the review of the facility documentation, the facility lacked a current food permit, and the document on file expired on 10.31.25”

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 observations and the review of four staff files, it was determined that the file for Staff #1 (DOE: 09.03.24), Staff #2 (DOE: 05.02.22), Staff #3 (DOE: 07.06.23), and Staff #4 (DOE: 07.06.23) lacked documentation of a background check.”

AAC R9-5-503.A.3.4. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: 3. At least one waterproof, sanitizable container with a waterproof liner and a tight fitting lid for soiled diapers; and 4. At least one waterproof, sanitizable container with a waterproof liner and a tight fitting lid for soiled clothing.

“Findings: Based on the Compliance Officer's observations, the diaper changing area lacked a soiled clothing container, and the soiled diaper container lacked a waterproof liner.”

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 observations, the diaper changing area was not seamless and smooth, the changing pad was not heat sealed, and the area was not maintained free of items not required for diapering; there was a box and a piece of paper on the diapering surface.”

AAC R9-5-501.B.9. B. 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 observations, the personal products in the diaper changing area were not labeled with the child's first and last name.”

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 the Compliance Officer's observations, the children in the library area were not supervised at all times. Children were playing "Hide and Seek", going under stuffed animals and a green bean bag, and multiple children were jumping on top of the bag and adding more pillows to the pile while the main staff member was attending to a child who was crying, and the other three staff members were sitting at a table away from enrolled children.”

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 children in the restroom: *There was a cracked tile on the wall below the toilet paper mount and a protruding screw at the base of the toilet.”

AAC R9-5-403.A. A. Within 10 calendar days of the starting date of employment or volunteer service, a licensee shall provide, and each staff member who provides child care services shall complete, training for new staff members that includes all of the following: 1. Facility philosophy and goals; 2. Names and ages of and developmental expectations for enrolled children for whom the staff member will provide child care services; 3. Health needs, nutritional requirements, any known allergies, and information about adaptive devices of enrolled children for whom the staff member will provide child care services; 4. Lesson plans; 5. Child guidance and methods of positive discipline, including separation; 6. Hand washing techniques; 7. Diapering techniques and toileting, if assigned to diaper changing duties; 8. Food preparation, service, sanitation, and storage, if assigned to food preparation; 9. If a staff member is assigned to feeding infants, the preparation, handling, and storage of infant formula and breast milk; 10. Recognition of signs of illness and infestation; 11. Child abuse or neglect detection, prevention, and reporting; 12. Accident and emergency procedures; 13. Staff responsibilities as required by A.R.S. Title 36, Chapter 7.1, Article 1 and this Chapter; 14. Sun safety policies and procedures; 15. Safety in outdoor activity areas; 16. Transportation procedures, if applicable; 17. Field trip procedures, if applicable; 18. Infant tummy time, if applicable; 19. Prevention of sudden infant death syndrome and use of safe sleeping practices, if applicable; and 20. Prevention of shaken baby syndrome, pediatric abusive head trauma, and child maltreatment.

“Findings: Based on the Compliance Officer's observations and the review of four staff files, the file for Staff #3 (DOE: 07.06.23) and Staff #4 (DOE: 07.06.23) lacked a 10-day new staff training, and the form in the file for Staff #1 (DOE: 09.03.24) was blank.”

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 child educator 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; or d. Employment or service as a volunteer in a licensed child care facility for 12 months;

“Findings: Based on the Compliance Officer's observations and the review of four staff files, it was determined that Staff #1 (DOE: 09.03.24) and Staff #2 (DOE: 05.02.22) acted in the capacity of a child educator assistant, and the files lacked staff qualifications.”

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 the Compliance Officer's observations and the review of the facility documentation, the facility lacked a current fire inspection permit, and the document on file expired on 03.07.25 Additionally, there was no documentation of a gas inspection. **Previously cited on 05.02.25”

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 observations and the review of the facility documentation, it was determined that 10 of 15 emergency contact cards lacked the following required information: *Child #1: The name and phone 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. *Child #2, Child #4, Child #6, Child #7, Child #8, Child #9, and Child #10: The name of the individual to be contacted in case of injury or sudden illness of the child. *Child #3: The name, address, email address, and phone number of each parent of the child. *Child #5: The name, address, email address, and phone number of each parent of the child, the name and phone 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. **Previously cited on 05.02.25”

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 observations and the review of the facility documentation, the facility's main posting area lacked the name of the facility director, the director stated she was not aware of her being the director, and the name of the individual designated to act on behalf of the facility director when the facility director is not present in the facility.”

AAC R9-5-302. 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. Guidelines for positive discipline reflective of age-appropriate methods for children that include clear, appropriate, consistent expectations; 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; 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; and 19. Policies and procedures for suspension and expulsion of children to include clear, appropriate, consistent expectations, including suspension and expulsion prevention strategies.

“Findings: Based on the Compliance Officer's observations, the family Handbook lacked the following required information: *Hours of operation. *Guidelines for positive discipline. *A statement that a parent has access to the areas on facility premises where the parent’s enrolled child is receiving child care services.”

AAC R9-5-501.B.6. B. A licensee shall ensure that a staff member: 6. For enrolled children five-years or younger, and except as provided in subsection (C), prepares, posts, and implements 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 the Compliance Officer's observation and the review of the facility documentation, the lesson plan lacked a date.”

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 and the Compliance Officer Supervisor's observations, in Room 31, the following hazard was accessible to enrolled children, there were cracks, splintering wood, and sharp edges on the baseboard of the East wall.”

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 observations, the following fall zones on the Playground lacked: *4" of the required 6" of sand under the first slide of the big red and white structure. *5" of the required 6" of sand under the second slide of the big red and white structure. *4" of the required 6" of sand under the white ladder of the big red and white structure. *4" of the required 6" of sand under the swingset.”

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 Supervisor's observations, 8 out of 17 reviewed Emergency, Information, and Immunization Record cards lacked: *Child #1- The name and contact telephone number of the child’s health care provider; *Child #2- The date of the child’s enrollment; *Child #3- The date of the child’s enrollment and the child's home telephone number; *Child #4- The date of the child’s enrollment and the name and contact telephone number of the child’s health care provider; *Child #5- The date of the child’s enrollment and the child's home telephone number; *Child #6- The date of the child’s enrollment, the child's home telephone number, and the name and contact telephone number of the child’s health care provider; *Child #7- The date of the child’s enrollment; and *Child #8- The date of the child’s enrollment and the child's home telephone number.”

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 and Compliance Officer Supervisor's observations, in Room 31's toilet room, there were marks of a brown substance on the handle of the cabinet under the sink.”

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 and Compliance Officer Supervisor's observations, the Fire Inspection Report on the facility premises was dated March 7, 2024, and had expired.”

AAC R9-5-403.A. A. Within 10 calendar days of the starting date of employment or volunteer service, a licensee shall provide, and each staff member who provides child care services shall complete, training for new staff members that includes all of the following:1. Facility philosophy and goals; 2. Names and ages of and developmental expectations for enrolled children for whom the staff member will provide child care services; 3. Health needs, nutritional requirements, any known allergies, and information about adaptive devices of enrolled children for whom the staff member will provide child care services; 4. Lesson plans; 5. Child guidance and methods of discipline; 6. Hand washing techniques; 7. Diapering techniques and toileting, if assigned to diaper changing duties; 8. Food preparation, service, sanitation, and storage, if assigned to food preparation; 9. If a staff member is assigned to feeding infants, the preparation, handling, and storage of infant formula and breast milk; 10. Recognition of signs of illness and infestation; 11. Child abuse or neglect detection, prevention, and reporting; 12. Accident and emergency procedures; 13. Staff responsibilities as required by A.R.S. Title 36, Chapter 7.1, Article 1 and this Chapter; 14. Sun safety policies and procedures; 15. Safety in outdoor activity areas; 16. Transportation procedures, if applicable; and 17. Field trip procedures, if applicable.

“Findings: Based on facility documentation and the Compliance Officer and Compliance Officer Supervisor's observations, Staff #3's (DOH 9/3/2024) file lacked documentation of new staff training done within 10 calendar days of the starting date of employment.”

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 and Compliance Officer Supervisor's observations in Room 31's first toilet room, the exhaust fan was inoperable.”

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 Compliance Officer’s observations, in Room #31 bathroom, there was a build up of dirt and scuff marks on the toilet seat 2 inches long.”

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 the Compliance Officer’s observations, in the Preschool Room, a vacuum was placed on the floor accessible to the enrolled children.”

AAC R9-5-301.F. F. A licensee shall ensure that a staff member submits, on or before the starting date of employment or volunteer services, one of the following as evidence of freedom from infectious active tuberculosis: 1. Documentation of a negative Mantoux skin test or other tuberculosis screening test recommended by the U.S. Centers for Disease Control and Prevention, administered within 12 months before the starting date of employment or volunteer service, that includes the date and the type of tuberculosis screening test; or 2. If the staff member has had a positive Mantoux skin test or other tuberculosis screening test, a written statement that the staff member is free from infectious active tuberculosis that is signed and dated by a health care provider within six months before the starting date of employment or volunteer service.

“Findings: Based on the Compliance Officer’s observation and review of 3 staff files, it was determined that 1 of the 3 staff files lacked documentation verifying that results of a negative Mantoux skin test given to a staff member was within 12 months before or on the starting date of employment. * Staff #1-starting date of employment-7/6/2023. The file had documentation indicating that a negative Mantoux skin test was read on 11/1/2023.”

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's observations and a review of 15 Emergency Cards, it was determined that 3 of 15 cards lacked documentation of some of the required information: *The card for Child #1 did not include the 2nd emergency contact. *The card for Child #2 did not include the doctor's name and phone number. *The card for Child #3 did not include the doctor's name and phone number.”

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 the Compliance Officer’s observation and a review of facility documentation, a current violation-free fire inspection from a local fire department was not available for the facility.”

AAC R9-5-403.A. A. Within 10 calendar days of the starting date of employment or volunteer service, a licensee shall provide, and each staff member who provides child care services shall complete, training for new staff members that includes all of the following:1. Facility philosophy and goals; 2. Names and ages of and developmental expectations for enrolled children for whom the staff member will provide child care services; 3. Health needs, nutritional requirements, any known allergies, and information about adaptive devices of enrolled children for whom the staff member will provide child care services; 4. Lesson plans; 5. Child guidance and methods of discipline; 6. Hand washing techniques; 7. Diapering techniques and toileting, if assigned to diaper changing duties; 8. Food preparation, service, sanitation, and storage, if assigned to food preparation; 9. If a staff member is assigned to feeding infants, the preparation, handling, and storage of infant formula and breast milk; 10. Recognition of signs of illness and infestation; 11. Child abuse or neglect detection, prevention, and reporting; 12. Accident and emergency procedures; 13. Staff responsibilities as required by A.R.S. Title 36, Chapter 7.1, Article 1 and this Chapter; 14. Sun safety policies and procedures; 15. Safety in outdoor activity areas; 16. Transportation procedures, if applicable; and 17. Field trip procedures, if applicable.

“Findings: Based on the Compliance Officer’s review of 3 staff files, it was determined that 1 of the 3 staff members did not have the required new staff training within 10 days of the starting date of employment. *Staff #1-starting date of employment-7/6/2023. The file lacked documentation that the new staff training was completed.”