Shepherd Of The Desert Lutheran Preschool - Mountain View Campus

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 the Compliance Officer's review of medications, the medication administration form for Children 1, 2, 3, 4, 5, 6, 7, and 8 only stated "allergy", rather than the symptom(s) that the child would present, so that staff would know when to administer the medication.”

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 the Compliance Officer's review of medications, Child 10's over-the-counter medication was not labeled with the child’s first and last name.”

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 the Compliance Officer's review of medications, Child #9's medication had expired on 2/28/2026.”

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 observations, the wood chips in the fall zones measured the following depths: *Toddler playground -2 to 4 inches of the required 6 inches at the base of the toddler slide and platform steps; and *Preschool playground- 4 inches of the required 6 inches at the base of the pink slide and under the base of the climbing globe”

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 observations, the water at the diapering sinks measured the following temperatures: *Room 1B- 80 degrees F; and * Room 2B-118 degrees F.”

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 review of the City of Scottsdale fire inspection that was completed in July 2024, the Fire Marshall had cited 5 fire code violations and that inspection was not approved.”

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 the Compliance Officer's observations, initially, 3 children were present in Room 4C but the roster had the names of only 2 children listed as present. Later during the inspection, 10 children were present but the roster listed the names of only 9 children as present.”

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 the Compliance Officer's inspection of the medications and on a discussion with staff, a child’s twin pack of EpiPens contained only 1 of the EpiPen injectors. The Director acknowledged the second injector was not on the premises and stated they had not obtained written permission from the child’s health care provider that would allow the EpiPens to be separated.”

AAC R9-5-605.A. A. A licensee shall install and maintain a portable, pressurized fire extinguisher that meets, at a minimum, a 2A-10-BC rating of the Underwriters Laboratories in a facility's kitchen and any other location required by Standard 10-1 of the International Fire Code, incorporated by reference in A.A.C. R9-1-412.

“Findings: Based on the Compliance Officer's observation, the arrow on the fire extinguisher in the hallway was in the “Recharge zone”.”

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 observations, it was determined that 2 out of 15 enrolled children's attendance forms reviewed lacked the following required information: Child #1: Release time on 4/9/2024. Child #2: Complete arrival and departure signatures on 4/9/2024.”

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 room 2B, the water temperature of the diaper changing handwashing sink was 78.8 degrees F, rather than between 86 - 110 degrees F as required.”

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 the Compliance Officer's observations of 2 outdoor activity areas, the following was observed on the 2’s playground: *There was discarded trash in an uncovered black trash container. *There was dried tree sap on the Step 2 climber roof and platform.”

AAC R9-5-515.F. F. A licensee shall ensure that:1. A dated, written notice of the communicable disease or infestation is prepared and posted in the facility’s entrance as required by R9-5-303; 2. Documentation of the notification is maintained on facility premises for 12 months from the date of the notification; and 3. Documentation of the absences of staff members and enrolled children due to a communicable disease or infestation listed in 9 A.A.C. 6, Article 2, Table 2, is prepared and maintained on facility premises for 12 months from the first date of absence.

“Findings: Based on staff statement, the Licensee failed to post a dated, written notice of a communicable disease or infestation in the facility's entrance. Staff stated a child was sent home a few weeks ago with pink eye and a second child with Fifth’s disease. Staff stated they emailed the parents.”

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 the Compliance Officer's observation, the medication form for Child #3 lacked a doctor's note to administer the medication. The medication stated "do not use unless directed by a doctor" for children ages 2 - 5 years old. Child #3 is 3 years old.”

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 observations of 2 outdoor activity areas, the following hazards were accessible to enrolled children on the Main playground: *There was cracked plastic with sharp edges on the basketball hoop stand. *There was cracked plastic with a sharp edge on the black water sensory bin.”