Pilgrim Lutheran Church and School

AAC R9-5-603.D. D. 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: *3 to 6 of the required 6 inches of sand in the fall zones under 7 swings. *4 of the required 6 inches of sand in the fall zone under the small overhead bars. *3 of the required 6 inches of sand in the fall zone of the curvy slide on the climbing structure.”

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, the roster in the classroom did not reflect the number of children present (9 children present, 11 listed on the roster).”

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, 2 out of 9 enrolled children's attendance forms lacked the time of departure and a signature for March 24, 2026.”

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 facility documentation and the Compliance Officer's observation, it was determined that 6 out of 10 enrolled children's Emergency, Information, and Immunization Record cards reviewed lacked the following required information: *Child #1, Child #2, and Child #3: The date of enrollment and the signature of the enrolling parent/guardian. Child #4: The date of enrollment and the contact telephone number for the child's health care provider. Child #5: The date of enrollment, the name and contact telephone 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, and the names and telephone numbers for two emergency contacts. Child #6: The Emergency Information and Immunization card was not available for review.”

AAC R9-5-403.B. B. A licensee shall ensure that:1. Each staff member who provides child care services completes 18 or more actual hours of training every 12 months after the effective date of this Chapter or the staff member’s starting date of employment or volunteer service in at least two topics listed in this subsection: a. Child growth and development, including: i. Infant growth and development, which may include sudden infant death syndrome prevention; ii. Developmental psychology; iii. Language development; iv. Observation and child assessment; v. Developmentally-appropriate activities; vi. Child guidance and methods of discipline which may include training on the appropriate techniques to prevent a child from harm or to prevent the child from harming others; and vii. Developmentally-appropriate activity areas; b. Health and safety issues, including: i. Accident and emergency procedures, including CPR and first aid for infants and children; ii. Recognition of signs of illness and infestation; iii. Nutrition and developmentally-appropriate eating habits; iv. Child abuse detection, reporting, and prevention; v. Safety of indoor and outdoor activity areas; and vi. Sun safety policies and procedures; c. Program administration, planning, development, or management; and d. Availability of community services and resources, including those available to children with special needs; and 2. As part of the required 18 hours of training in subsection (B)(1): a. A staff member who has less than 12 months of child care experience before the staff member’s starting date, completes at least 12 hours in one or more of the topics in subsection (B)(1)(a) in the staff member’s first 12 months at the facility; b. A staff member who has 12 months or more of child care experience, completes at least 6 hours in one or more of the topics in subsection (B)(1)(a) every 12 months after the staff member’s starting date; c. A staff member who provides child care services to an infant completes at least 6 hours in subsection (B)(1)(a)(i) every 12 months after the staff member’s starting date; and d. A facility director completes at least 6 hours in subsection (B)(1)(c) every 12 months after the facility director’s starting date.

“Findings: Based on facility documentation and the Compliance Officer's observation, it was determined that 2 of 2 staff files reviewed lacked the following required training documentation: Staff #1: 18 of 18 annual training hours for the time period of 8/15/2023 - 8/15/2024. Staff #2: 9 of 18 annual training hours for the time period of 1/5/2024 - 1/5/2025.”

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: *3 of the required 6 inches of sand in the fall zones of the swings and the monkey bars. *4 of the required 6 inches of sand in the fall zones of the long slide of the play structure. *1 of the required 6 inches of sand in the fall zones of the rope ladder of the play structure.”

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 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 a pair of scissor and a reclosable plastic bag of at lease one-gallon size.”

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 3 out of 10 enrolled children's attendance forms lacked the following information: *Child #6: A release time for 3/28 and 3/29/2024. *Child #7: A release time for 3/29/2024. *Child #8: A release time and signature for 4/8/2024.”

AAC R9-5-309.A. A. An applicant shall obtain the following inspections of a facility and make any repairs or corrections stated on an inspection report before a license is issued by the Department: 1. If there are gas pipes that run from a gas meter to an appliance or location on the facility premises, a gas inspection by a licensed plumber or individual authorized by the local jurisdiction that verifies there are no gas leaks in the gas pipes that run from the gas meter to any appliance or location on facility premises; and 2. A fire inspection by a local fire department.

“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 R9-5-403.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.

“Finding: Based on facility documentation and the Compliance Officer's observation, it was determined that the file for Staff #1 lacked documentation for the 10-day training for new staff members. (start date- 8/15/2023).”

AAC R9-5-403.B. B. A licensee shall ensure that:1. Each staff member who provides child care services completes 18 or more actual hours of training every 12 months after the effective date of this Chapter or the staff member’s starting date of employment or volunteer service in at least two topics listed in this subsection: a. Child growth and development, including: i. Infant growth and development, which may include sudden infant death syndrome prevention; ii. Developmental psychology; iii. Language development; iv. Observation and child assessment; v. Developmentally-appropriate activities; vi. Child guidance and methods of discipline which may include training on the appropriate techniques to prevent a child from harm or to prevent the child from harming others; and vii. Developmentally-appropriate activity areas; b. Health and safety issues, including: i. Accident and emergency procedures, including CPR and first aid for infants and children; ii. Recognition of signs of illness and infestation; iii. Nutrition and developmentally-appropriate eating habits; iv. Child abuse detection, reporting, and prevention; v. Safety of indoor and outdoor activity areas; and vi. Sun safety policies and procedures; c. Program administration, planning, development, or management; and d. Availability of community services and resources, including those available to children with special needs; and 2. As part of the required 18 hours of training in subsection (B)(1): a. A staff member who has less than 12 months of child care experience before the staff member’s starting date, completes at least 12 hours in one or more of the topics in subsection (B)(1)(a) in the staff member’s first 12 months at the facility; b. A staff member who has 12 months or more of child care experience, completes at least 6 hours in one or more of the topics in subsection (B)(1)(a) every 12 months after the staff member’s starting date; c. A staff member who provides child care services to an infant completes at least 6 hours in subsection (B)(1)(a)(i) every 12 months after the staff member’s starting date; and d. A facility director completes at least 6 hours in subsection (B)(1)(c) every 12 months after the facility director’s starting date.

“Findings: Based on facility documentation and the Compliance Officer's observation, it was determined that 1 out of the 2 staff files reviewed lacked the required training documentation: Staff #2: 9 of the required 18 hours of training for the period of 1/5/2022 - 1/5/2023.”

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 facility documentation and the Compliance Officer's observation, it was determined that 5 out of 8 enrolled children's Emergency, Information, and Immunization Record cards reviewed lacked the following required information: *Child #1 & Child #3: The date of the child's enrollment. *Child #2: The name and contact phone number of the child's health care provider. *Child #4: The date of the child's enrollment and the parent's signature. *Child #5: The name and contact phone number of the child's health care provider and the name of the individual to be contacted in case of sudden illness or injury.”

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 observation, in the Preschool classroom, there were 2 cans of Barbasol shaving cream on a rolling cart accessible to enrolled children. The shaving cream cans were labeled "Keep out of reach of children."”