Risen Savior Lutheran Church

AAC R9-5-305.A. A. A licensee shall not permit an enrolled child to attend a facility until the facility receives: 1. An immunization record for the enrolled child with the information required in 9 A.A.C. 6, Article 7, documenting that the enrolled child has received all current, age-appropriate immunizations required under 9 A.A.C. 6, Article 7: a. Provided by a healthcare provider, or b. Generated from the Arizona State Immunization Information System, which is the Department’s child immunization reporting system established in A.R.S. § 36-135; or 2. An exemption affidavit for the enrolled child provided by the enrolled child’s parent that contains a statement, signed by the enrolled child's: a. Health care provider, that the immunizations required by 9 A.A.C. 6, Article 7 would endanger the enrolled child’s health or medical condition; or b. Parent, that the enrolled child is being raised in a religion whose teachings are in opposition to immunization.

“Findings: Based on facility documentation and the Compliance Officer’s observations, it was determined that 2 out of 15 enrolled children's Emergency, Information, and Immunization Record cards lacked attached written immunization records: Child #3 and Child #9.”

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 facility documentation and the Compliance Officer's observations Staff #4 (employment date 08/11/2025) and Staff #5 (employment date 03/21/2025) were assistant child educator's. Staff #4 and Staff #5 were not qualified as assistant child educator's because the staff files lacked documentation of a high school diploma/equivalency diploma or current and continuous enrollment in high school/equivalency classs.”

AAC R9-5-402.A. A. A licensee shall maintain a file for each staff member containing: 1. The staff member’s name, date of birth, home address, and telephone number; 2. The staff member’s starting date of employment or volunteer service; 3. The staff member’s ending date of employment or volunteer service, if applicable; 4. The name and telephone number of an individual to be notified in case of an emergency; 5. The staff member’s written statement attesting to current immunity against measles, rubella, diphtheria, mumps, and pertussis; 6. The form required in A.R.S. § 36-883.02(C); 7. Documents required by R9-5-203; 8. Documents required by R9-5-301; 9. Documents required by R9-5-401, if applicable; 10. If applicable: a. The form required in A.R.S. § 8-804(I), b. Documentation of the submission required in A.R.S. § 8-804 and the information received as a result of the submission, and c. Documentation of training provided by a licensee as required by R9-5-403, if applicable; 11. A copy of any current license or certification required by A.R.S. Title 36, Chapter 7.1, Article 1. or this Chapter; and 12. Documentation of the requirements in A.R.S. § 36-883.02(D).

“Findings: Based on facility documentation and the Compliance Officer's observations, it was determined that the files for Staff #2 (employment date 07/15/2025), Staff #4 (employment date 08/11/2025), and Staff #5 (employment date 03/21/2025) lacked documentation of 2 good faith efforts to contact professional references. Refer to A.R.S. § 36-883.02(D).”

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 facility documentation and the Compliance Officer’s observation, it was determined that the file for staff #5 (employment date 03/21/2025) lacked documentation of the 10-day training for new staff members.”

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, Room 201 lacked a daily schedule.”

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 facility documentation and the Compliance Officer's observations, it was determined that Room 101 lacked a current lesson plan (dated 02/17/2026-02/20/2026) and Room 201 lacked a lesson plan.”

AAC R9-5-504.A.9.a. A. A licensee providing child care services for 1-year-old and 2-year-old children shall: 9. Ensure that: a. If finger food is served, the food is of a size and texture that does not present a choking hazard;

“Findings: Based on the Compliance Officer's observations, in Room 101, one-year-old children were observed eating whole mandarin orange segments and whole dinner rolls.”

AAC R9-5-512.F.4.5. F. A licensee shall ensure that: 4. Except for a cup or receptacle used only for water, food waste is stored in a covered container and the container is clean and lined with a plastic bag; 5. Food waste and other refuse is removed from the facility building at least once every 24 hours or more often as necessary to maintain a clean condition and avoid odors;

“Findings: Based on the Compliance Officer's observations, in Room 108 and Room 207, the receptacles used for food waste lacked lids.”

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 observations, it was determined that the following enrolled children's medication was expired or the medication is no longer being administered and had not been returned to the parent: Child #4: Medication authorization form end date 12/09/2025. Child #11: Medication #1 expired 01/2025 and Medication #2 expired 05/2025.”

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 facility documentation and the Compliance Officer’s observation, it was determined that 9 out of 15 enrolled children's Emergency, Information and Immunization Record Cards reviewed lacked the following required information: Child #2, Child #3, and Child #6: The date of enrollment. Child #5: The Emergency, Information and Immunization Record Card. Child #1: The date of enrollment. The name, address, and phone number of the second parent. Child #4: The name and phone number of the child’s health care provider. Child #7: The name and phone number of the child’s health care provider. The name of the individual to be contacted first in case of injury or sudden illness. Child #8: The signature of the enrolled child's parent. Child #9: The name and phone number of the child’s health care provider. The name of the individual to be contacted first in case of injury or sudden illness. The second page of the card containing the parent's signature and the written instructions noting the child's dietary needs, the susceptibility to illness, any physical conditions of which a staff member should be aware of, and any individual requirements for health maintenance.”

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 (employment date 09/05/2025), Staff #2 (employment date 07/15/2025), Staff #3 (employment date 02/18/2025), and Staff #5 (employment date 03/21/2025) lacked documentation that the Fingerprint Clearance Cards were validated prior to the staff members employment dates. The fingerprint clearance cards were verified to be valid through the DPS website at the time of the inspection.”

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 facility documentation and the Compliance Officer's observation, it was determined that the Criminal History Affidavits for Staff #1 (employment date 09/05/2025), Staff #2 (employment date 07/15/2025), Staff #3 (employment date 02/18/2025), Staff #4 (employment date 08/11/2025), and Staff #5 (employment date 03/21/2025) lacked the facility name and the address or CDC number of the location.”

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 observations, it was determined that the Medication Authorization Forms for the enrolled children lacked the following required information: Child #10: The end date of the dosage period. The prescription number of the medication. The route of administration. Child #4: The reason for the medication. The frequency of administration. Child #12: The name of the medication. The frequency of administration.”

AAC R9-5-309.B. B. If there are gas pipes that run from a gas meter to an appliance or location on the facility premises, a licensee shall ensure that a licensed plumber or individual authorized by the local jurisdiction conducts a gas inspection 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 at least once every 12 months after the issue date of the license.

“Findings: Based on the Compliance Officer's observations, the gas inspection report was not available for review.”

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, upon entering the following classrooms, the rosters did not reflect the number of children present: In the 2A classroom, the roster indicated 11 children, but there were 12 children present in the room. In the 2B nap room, the roster was not able to be reviewed as it was in the 2B classroom. In the 4B classroom, the roster indicated 14 children, but there were 15 children present in the room.”

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 observation, the 1B classroom and 4B classroom lacked a posted capacity.”

AAC R9-5-514. D. D. 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, the 1B classroom and 4B classroom lacked a posted building evacuation plan.”

AAC R9-5-501.C.4. C. A licensee shall ensure that a staff member:4. Except as provided in subsection (D), prepares and posts 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. 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 1B classroom lacked a posted daily schedule.”

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, the fire inspection report was not available for review.”

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 Compliance Officer #1's observation, it was determined that the medication for Child #7 had expired on 01/2024 and had not been returned to the parent.”

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 Compliance Officer #1's observation, it was determined that Child #6 and Child #7 lacked 1 of 2 doses of the medication prescribed by the health care provider in the container dispensed by the pharmacy.”

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 Compliance Officer #1's observation, it was determined that the following medication authorization forms were incomplete: Child #5: Lacked the end date of the dosage period and the date the parent gave authorization to administer the medication. Child #6: Lacked the times and frequency of administration.”

AAC R9-5-512.F. 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; 2. Staff members wash their hands with soap and running water after toileting; 3. An enrolled child’s hands are washed with soap and running water after toileting; 4. Except for a cup or receptacle used only for water, food waste is stored in a covered container and the container is clean and lined with a plastic bag; 5. Food waste and other refuse is removed from the facility building at least once every 24 hours or more often as necessary to maintain a clean condition and avoid odors; 6. A staff member or an enrolled child does not draw water for human consumption from a toilet room handwashing sink; 7. Toys, materials, and equipment are maintained in a clean condition; 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 Compliance Officer #1's observation, in room 207's toilet room, art work was placed on the wire rack and floor to dry.”

AAC R9-5-502.C.3.a. C. A licensee shall ensure that: 3. When preparing, using, or caring for an infant's feeding bottles, a staff member: a. Labels each bottle received from the parent with the infant's name;

“Findings: Based on Compliance Officer #1's observation, in the Infant room, there were 4 bottles labeled with the enrolled child's first name only and 2 bottles lacked a label.”

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 Compliance Officer #1's observation, in the Infant room, there were 8 packages of wipes labeled with the enrolled child's first name only.”

AAC R9-5-501.C.5. C. A licensee shall ensure that a staff member:5. Except as provided in subsection (D), prepares and posts 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 facility documentation and Compliance Officer #1's observation, room 101 and room 206 lacked a lesson plan posted in the activity area. Room 207 lacked a current lesson plan, the lesson plan that was posted was dated for 02/26/2024-03/01/2024.”

AAC R9-5-501.C.4. C. A licensee shall ensure that a staff member:4. Except as provided in subsection (D), prepares and posts 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. 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 facility documentation and Compliance Officer #1's observation, room 101, room 206, and room 209 lacked a daily schedule posted in the activity area.”

AAC R9-5-402.A. A. A licensee shall maintain a file for each staff member containing:1. The staff member’s name, date of birth, home address, and telephone number; 2. The staff member’s starting date of employment or volunteer service; 3. The staff member’s ending date of employment or volunteer service, if applicable; 4. The name and telephone number of an individual to be notified in case of an emergency; 5. The staff member’s written statement attesting to current immunity against measles, rubella, diphtheria, mumps, and pertussis; 6. The form required in A.R.S. § 36-883.02(C); 7. Documents required by R9-5-203; 8. Documents required by R9-5-301; 9. Documents required by R9-5-401, if applicable; 10. If applicable: a. The form required in A.R.S. § 8-804(I), b. Documentation of the submission required in A.R.S. § 8-804 and the information received as a result of the submission, and c. Documentation of training provided by a licensee as required by R9-5-403, if applicable; 11. A copy of any current license or certification required by A.R.S. Title 36, Chapter 7.1, Article 1. or this Chapter; and 12. Documentation of the requirements in A.R.S. § 36-883.02(D).

“Findings: Based on facility documentation and Compliance Officer #2’s observation, 3 of the 4 staff files reviewed lacked the following: Staff #1 and Staff #4 lacked two of the required good faith effort references. Staff #2 lacked 1 of the required 2 good faith effort references.”

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 Compliance Officer #2's observation, 4 of 15 children's Emergency, Information, and Immunization Record cards review lacked the following: Child #1: One of the required two emergency contact names and phone numbers. Child #2: Two of the required two emergency contact names and phone numbers. Child #3: One of the required two emergency contact names and phone numbers. Child #4: Date of enrollment; the name of the individual to call first in case of the child's sudden illness or injury.”

AAC R9-5-203.G. G. If required by A.R.S. § 8-804, before an individual’s starting date of employment or volunteer service, a licensee shall comply with the submission requirements in A.R.S. § 8-804(C) for the individual.

“Findings: Based on facility documentation and Compliance Officer #2’s observation, 4 of the 4 staff files viewed lacked the following: Staff #1, Staff #2, and Staff 3, Staff #4 lacked documentation of the DCS submittal requirements. 4/4 lacked documentation of the submittal requirements to DCS.”

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 Compliance Officer #2’s observation, 4 of the 4 staff files lacked the following: Staff #1, Staff #2, Staff #3, Staff #4’s files lacked documentation DPS was contacted to verify the validity of their fingerprint clearance cards. No documentation was available.”

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 #1's observation, in room 201's toilet room, 3 blue chairs were stacked and placed against the wall under the coat hangers.”