Primrose School of Fletcher Heights

AAC R9-5-502.B.7. B. A licensee providing child care services for infants shall not: 7. Permit an infant to sleep in a playpen, pack and play, car seat, stroller, swing, bouncer, high chair, or other equipment not intended for sleep purposes.

“Findings: Based on staff statements and the Compliance Officers' observations, an infant slept in a bouncer for 15-30 minutes. Staff stated: *** Infant was asleep in bouncer for "around 15-30 minutes" before staff reported the situation. *** There was an infant "left in the bouncer asleep."”

AAC R9-5-508.G. G. In addition to the required daily servings of food stated in subsection (C), a licensee: 1. Shall make second servings of food available to each enrolled child at meals and at snack time, 2. May substitute a food that is equivalent to a specific food component if second servings of the specific food component are not available, and 3. Shall ensure that a food substitution in subsection (G)(2) is written on the posted weekly menu by the end of the meal or snack service.

“Findings: Based on facility documentation and the Compliance Officers' observations, a menu with written food substitutions was not posted by the end of the meal or snack service. *** On 08/14/2026, the menu listed Cheerios, peaches, and milk for breakfast. Children were served French toast sticks and mandarin oranges.”

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 Officers' observations, the younger infant room (Room 1) lacked a soiled diaper bin with a tight-fitting lid.”

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: Per allegation and the Compliance Officers' observations, in Room 4, the bathroom trash can was accessible to children and was being used for soiled diapers. Staff stated: *** "One kid takes off [their pull-up] in the bathroom and throws it in the bathroom trash," and that it happened "last week a few times." *** "Pull-ups are taken off in the bathroom and thrown there; one kid usually does it 1-2 times a week."”

AAC R9-5-512.F.1. 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;

“Findings: Per allegation and based on Staff statements and the Compliance Officers' observations, there were no paper towels in an operable, mounted dispenser in Room 4's bathroom. Staff stated: ***Paper towels are "empty two times a week." ***Paper towels are "not working once a week." ***Paper dispenser is "not working two days a week." ***Paper towels are "always empty in the bathroom."”

AAC R9-5-508.C. C. If a licensee provides food, a licensee shall prepare and serve food according to the meal pattern requirements found in Table 5.1, "Meal Pattern Requirements for Children."

“Findings: Per allegation and the Compliance Officers' observations, children were not served milk for breakfast in all classrooms. Milk was listed on the posted menu. The menu from July 6, 2026, to August 14, 2026 listed milk for breakfast, but milk was not served during this timeframe. Staff stated: *** "Sometimes milk is spilt, so there is no milk." *** "There is no milk" at breakfast. *** "Milk is in the cart 1-2 times a week, but no milk is served for breakfast." *** For breakfast, there is "no milk." *** "Milk has not been served in a while" for breakfast. For lunch, staff did not give all children the age-appropriate milk portion serving according to meal pattern requirements. Staff are responsible for distributing milk during lunch. Staff stated: *** At lunchtime, "1/2 gallon of milk is served" and for allergies, "water is substituted." *** "Leads are in charge" of serving milk at lunchtime. *** Milk is "staff duty" for lunch, and "kids who don't want milk drink water." *** Staff "offer kids milk if they want it" during lunch and "one kid with allergies brings their own milk." *** Staff are "in charge of serving" milk at lunch. *** Milk is given to children "unless there is a huge lunch," and depending on the child, some are "given less." ***"Milk is not served so that children will eat lunch."”

AAC R9-5-502.A.8.b. A. A licensee providing child care services for infants shall: 8. Provide a crib for each infant that: b. Has a commercially waterproofed mattress; and

“Findings: Based on the Compliance Officers' observation, in the Infant 1 and Infant 2 classrooms, there were 9 mattresses that had tears and holes making them no longer waterproof.”

AAC R9-5-502.C.1.lk. C. A licensee shall ensure that: 1. A staff member providing child care services in an infant room: k. Obtains written, current, and dated dietary instructions from a parent or health care provider regarding the method of feeding and types of foods to be prepared or fed to an infant at the facility;

“Findings: Based on the Compliance Officers' observation, in the Infant 1 and Infant 2 classrooms, 2 infant feeding instructions lacked the required information: Child #1: Lacked times and frequencies of food to be fed to the child. Child #2: Lacked the types of food to be fed to the child.”

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 Officers' observation, in the toddler classroom. the diaper table had a build up of dark gray substance and exposed raw wood making it no longer seamless and smooth.”

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 Officers' observation the following diaper changing sink temperatures were: Infant #1 and Infant #2: *The temperature of the diaper changing sink was 85° F rather than 86 °F-110°F as required. Toddlers Room: *The temperature of the diaper changing sink was 84 ° F rather than 86 °F-110°F as required. EPS and Room #3: *The temperature of the diaper changing sink was 80 °F rather than 86 °F-110°F as required.”

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 Officers' observation in room #7, the toilet seat had areas of exposed raw wood.”

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 Officers' observation, 3 medication forms lacked the following information: *Child #2, Child #3, and Child #4: Lacked the times and frequencies of the medication to be administered.”

AAC R9-5-605.B.1. B. A licensee shall ensure that:1. All designated exits, corridors, and passageways that provide escape from the building are unobstructed and unlocked during hours of operation;

“Findings: Based on the Compliance Officer’s observation, the following designated exits that provide escape from the building were blocked: Classroom 10: *A rocking chair blocked the exit. Classroom 6: *There were 2 children on cots sleeping, blocking the exit. Classroom 8 *There was 1 child on a cot and 1 staff blocking the exit.”

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 hazards were accessible to enrolled children: Preschool Playground: *There was bird feces on 2 swing seats. *There was a garden hose loose and uncoiled. 4-5K Playground: *There was a tear in the turf under the tire swing. *There was a trash can with food waste that lacked a lid. Toddler Playground: *There was a plastic table leaning against the wall. *There was torn rubber on the treehouse. Large Toddler Playground: *There was a 3-inch rusted hole on the northeast fence panel behind the climber with sharp metal. *There was an abundance of bird feces on the base of the North fence panels. *There were 2 areas, 4-6 inches of sharp metal at the base of the North fence panels. Primrose Patch: *There was a 12-16 inch area of torn turf on the garden box.”

AAC R9-5-511.C. C. A licensee shall provide an unobstructed passageway at least 18 inches wide between each row of cots or mats to allow a staff member access to each enrolled child.

“Findings: Based on the Compliance Officer’s observation, in Classroom 6, 2 of the occupied mats were spaced 2-4 inches apart rather than the required 18 inches between rows as required.”

AAC R9-5-505. A licensee providing child care services for 3-year-old, 4-year-old, and 5-year-old children shall provide a supply of age appropriate toys, materials, and equipment accessible to enrolled children in each activity area in a quantity sufficient to meet the needs of the enrolled children in attendance including:1. Art supplies, 2. Blocks, 3. Books and posters, 4. Toys and dress-up clothes, 5. Indoor and outdoor equipment to enhance large muscle development, 6. Puzzles and toys to enhance manipulative and categorization skills, 7. Science materials, and 8. Musical instruments.

“Findings: Based on the Compliance Officer’s observation, Classroom 7 lacked enough books to meet the needs of the enrolled children. There were 7 books for 15 children.”

AAC R9-5-503.A.4. A. A licensee shall ensure that each diaper changing area required in R9-5-601(4) contains: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 observation, in Classrooms 1, 2, 3, 4, 5, and 6, the soiled clothes container lacked a tight-fitting lid. Classrooms 7 and 8 lacked soiled clothes containers.”

AAC R9-5-503.A.3. 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

“Findings: Based on the Compliance Officer’s observation, in Classrooms 1, 2, 3, and 11, the soiled diaper container lacked a tight-fitting lid.”

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 Classrooms 3 and 10, the diaper changing area lacked single-use paper hand towels from a dispenser.”

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, Classroom 1's diaper changing surface had peeling sealant, exposing raw wood at the back corner of the diaper changing surface and the front corner near the sink. Classroom 11 had 3 shoes and a plastic bin next to the sink, and 9 large plastic animals in the diaper changing sink.”

AAC R9-5-502.C.1.l. C. A licensee shall ensure that:1. A staff member providing child care services in an infant room: l. Obtains written, current, and dated dietary instructions from a parent or health care provider regarding the method of feeding and types of foods to be prepared or fed to an infant at the facility;

“Findings: Based on facility documentation and the Compliance Officers' observations, it was determined that the written dietary instructions for 8 infants lacked the types of foods to be prepared and fed to an infant at the facility.”

AAC R9-5-501.C.9. C. 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 observation, the following personal products lacked the required information: Classroom 1: *There were 2 diaper creams and 4 wipes that lacked the enrolled child's last name. Classroom 2: *There was 1 diaper cream and 1 wipe that lacked the enrolled child's last name. Classroom 3: *There was 1 lotion and 3 wipes that lacked the enrolled child's last name. Classroom 11: *There were 2 sunscreens, 3 diaper creams, and 3 wipes that lacked the enrolled child's last name.”

AAC R9-5-502.A.5.d. A. A licensee providing child care services for infants shall:5. Develop, document, and implement tummy time policies and procedures that: d. Ensure, as an infant demonstrates ability and strength to control physical movement and greater sensory perception and social interaction, an assigned staff member provide a tummy-time period to: i. A 2 - 3 month old infant of no more than 15 minutes; ii. A 3 - 4 month old infant of no more than 20 minutes; and iii. A 5 - 6 month old infant of 20 minutes; and

“Findings: Based on facility documentation and the Compliance Officer’s observation, the Infant classroom lacked documentation of tummy time.”

AAC R9-5-502.A.8.b. A. A licensee providing child care services for infants shall: 8. Provide a crib for each infant that: b. Has a commercially waterproofed mattress; and

“Findings: Based on the Compliance Officer’s observation, in the Infant Classroom, 5 mattresses had frayed holes at the edges and corners, making them no longer waterproof.”

AAC R9-5-503.F.2. F. A licensee shall ensure that in an activity area with a diaper changing area:2. A staff member: a. Documents each diaper change: i. For an infant, in the infant’s dated, daily, documentation required in R9-5-502(C)(1)(d); or ii. For an enrolled child who is not an infant, in a dated diaper changing log; b. Maintains the diaper changing log on facility premises for 12 months after the date of the diaper changing log; c. Empties clothing soiled with feces into a flush toilet without rinsing; d. Places an enrolled child’s clothing soiled by feces or urine in a plastic bag labeled with the enrolled child’s name, stores the clothing in a container used for this purpose, and sends the clothing home with the enrolled child’s parent; and e. Removes disposable diapers and disposable training pants from a diaper changing area as needed or at least twice every 24 hours to a waste receptacle outside the facility building.

“Findings: Based on staff statements and the Compliance Officer's observations, in Classrooms 3, 4, and 5, the soiled clothing containers were full, some were not labeled, and none were sent home. Staff Statement: *We try to send them home daily; those have been here for a while.”

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 statements, a staff member failed to supervise each enrolled child at all times. The following statements were made by staff and children: *I see incidents happen the majority of the time, unless it happens behind my back. *Child #1 was hit on the back by a book that was thrown up in the air and the staff told me they did not see it happen. *Staff #1 heard the book hit Child #1 but did not see it happen. *Child #1 was hit on their back by a book that was thrown by another child, but I did not see it due to my back being turned away from the child. *I threw a book at (Child #1) and it hit (Child #1) on (Child #1's) back. It made a tiny sound. My friend (Child #1) cried. *I saw a book hit (Child #1's) back and (Child #1) cried.”

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 the Toddler 1 classroom (1 year olds), the edging at the front and rear of the diaper changing surface (near the handwashing sink) was cracked and rough to the touch causing it not to be sanitizable.”