Lord Of Grace Lutheran Church

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.

“Compliance Officer 1 reviewed the medication and medication forms for Child 3 and observed that the medication is prescribed as a two-pack but there was only one of two medications in the box. The Director acknowledged that the facility did not have a note from the doctor authorizing that the medication could be separated.”

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

“Compliance Officer 1 reviewed the prescription medication for Child 3 and observed that it had an expiration date of 02/2024.”

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.

“Compliance Officer 2 reviewed two personnel files and observed the following: * Staff 1 was missing a copy of the backside of her fingerprint clearance card (starting date of employment 08/08/17).”

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.

“Upon arrival at the facility, the Compliance Officers observed that the children were in the fellowship hall watching a presentation by the fire department. The Compliance Officers confirmed that the fellowship hall is not licensed for use and would have to be considered a field trip. The Director acknowledged that they have been using the fellowship hall for "early bird" (before school) use and for special visitors.”

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.

“Compliance Officer 1 reviewed the sign-in and out logs for April 2024 in room #2 and observed the following: * Child 1 was signed-out with initials only 04/03, 04/05, 04/08, and 04/09. * Child 2 was signed-in with initials only on 04/09.”