YMCA at Monte Vista

AAC R9-5-713.A. A. A licensee shall: 1. Designate a facility director who acts on behalf of the licensee and is responsible for the daily on-site operation of a facility; 2. Submit the name of the designated facility director in a written notice to the Department before a license is issued; 3. Except as provided in subsection (A)(4), within 10 calendar days before changing a facility director, submit written notice of the change including the new designated facility director’s name and starting date; 4. If the licensee is not aware of a change in the facility director 10 calendar days before the effective date of the change, submit written notice of the change to the Department including the new designated facility director’s name and starting date within 72 hours after becoming aware of the change.

“Findings: Based on the Compliance Officer’s observations, the licensee failed to notify the Department of a change in the facility director within 10 calendar days.”

AAC R9-5-717.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 the Compliance Officer's observations of 8 reviewed files, Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #8's files lacked documentation of immunization records.”

AAC R9-5-731.A. A. A licensee that prepares food for enrolled children on facility premises shall, if required by 9 A.A.C. 8, Article 1, and the local ordinances of the local health department where the facility is located, obtain a food establishment permit issued under 9 A.A.C. 8, Article 1, and: 1. Submit to the Department a written notice of the facility’s food establishment permit before the Department issues a license to the facility, 2. Maintain the facility’s current food establishment permit on the facility’s premises, and 3 Provide a written notice of the facility’s current food establishment permit to the Department upon request.

“Findings: Based on facility documentation and the Compliance Officer’s observations, the facility lacked documentation of a current food establishment permit. The permit on site available for review expired on 7/31/2026.”

AAC R9-5-744.B.9. B. A licensee shall ensure that: 9. Toilet rooms are ventilated to the outside of the building, either by a screened window open to the outside air or by an exhaust fan and duct system that is operated when the toilet room is in use;

“Findings: Based on the Compliance Officer's observation, the Cafeteria Girls' and Boys' restrooms lacked operable exhaust systems. *Previously cited as R9-5-605.B.10 on 12/04/2024 and 9/19/2024.”

AAC R9-5-742.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, in the Southeast Playground, the fall zones under the two swing sets lacked 4 inches of the required 6 inches of wood chip resilient surfacing.”

AAC R9-5-721.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 observation, there was no fire inspection report available for review.”

AAC R9-5-716.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 R9-5-731(C)(13); 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, 5 of 10 Emergency, Information, and Immunization Record (EIIR) cards reviewed lacked the following information: Child #1 and #2: The child's sex. Child #3: *The last name of the enrolled child's parent. *The signature and date on the EIIR card. Child #4: *The name and contact number for the second emergency contact. *The name and contact number of the child's health care provider. Child #5: *The name and contact number for the child's health care provider. *The signature and date on the EIIR card.”

AAC R9-5-501.A.12. A. A licensee shall ensure that: 12. The facility premises, including the buildings, are maintained free from hazards;

“Findings: Based on CO's observations, in the Cafeteria, there was a 3-feet x 2-feet area of spilled water on the floor in front of the drinking fountains, accessible to enrolled children.”

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 Compliance Officer's (CO) observations and a review of 3 staff files, Staff #1 (DOE 09/09/2024) lacked documentation of a completed DCS affidavit. REFERENCE: R9-5-203.G”

AAC R9-5-605.B.10. B. A licensee shall ensure that:10. Toilet rooms are ventilated to the outside of the building, either by a screened window open to the outside air or by an exhaust fan and duct system that is operated when the toilet room is in use;

“Findings: Based on CO's observations, the exhaust systems in the Cafeteria Girls' and Boys' restrooms were not working.”

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 CO's observations, on the northwest playground, four stepping pods had exposed bolts on the top of the steps, accessible to enrolled children”

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 CO's observations and a review of facility documentation, Child #7 had two medications with both medications documented on one authorization form. In addition, the medication authorization lacked a route, end date, times and frequency, and the prescription number for the two medications did not match the numbers on the authorization. *Previous deficiency 09/20/2023”

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 CO's observations, food waste was in 2 uncovered garbage cans in the Cafeteria, 1 of 5 toilets in the Cafeteria Girls' restroom was locked and unable to access, and 3 of 4 drinking fountains on the school-age playgrounds were not operational. *Previous deficiency on 09/20/2023 and 04/03/2023”

AAC R9-5-501.A.12. A. A licensee shall ensure that: 12. The facility premises, including the buildings, are maintained free from hazards;

“Findings: Based on CO's observations, in the Cafeteria Girls' restroom, there was a 5-feet x 5-feet area of spilled water on the floor in front of the sinks, accessible to enrolled children.”

AAC R9-5-404.E. E. In addition to maintaining the required staff-to-children ratios, a licensee shall ensure that:1. Staff members are present on facility premises to perform facility administration, food preparation, food service, and maintenance responsibilities; and 2. Facility maintenance does not depend on the work of enrolled children.

“Findings: Based on CO's observations and staff interview, the Director was acting as a teacher caregiver and performing childcare duties. There was only 1 other staff present, and the Director was not able to assist with a walk-through of the facility. Doors were locked to the facility areas, and the Director provided their keys to the CO to access the locked areas. *Previous deficiency 09/20/2023”

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.

“Findings: Based on CO's observations and a review of 2 staff files, Staff #1's (DOE 09/09/2024) 10-day training was not completed within 10 calendar days of the starting date of employment. The 10-day training form was blank.”

AAC R9-5-401.3. A licensee shall ensure that staff members meet the following qualifications for employment or volunteer service at a facility:3. A teacher-caregiver is 18 years of age or older and provides the licensee with documentation of one of the following: a. Six months of child care experience and: i. A high school diploma or high school equivalency diploma; or ii. At least 12 credit hours from an accredited college or university, including at least six credit hours in early childhood, child development, or a closely-related field; b. Associate or bachelor degree from an accredited college or university in early childhood, child development, or a closely-related field; or c. N.A.C., C.D.A., or C.C.P. credential;

“Findings: Based on CO's observations and a review of 2 staff files, Staff #1 (DOE 09/09/2024) acted in the capacity of a teacher caregiver and lacked documentation of the education and experience to qualify.”

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 CO's observations and a review of facility documentation, the facility lacked a current, violation-free gas inspection. The inspection reviewed expired on 07/20/2024.”

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 CO's observations and a review of facility documentation, in the Cafeteria, there were 26 children present and 21 children noted on the roster as in attendance. *Previous deficiency on 09/20/2023 and 04/03/2023”

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 CO's observations and a review of facility documentation, 3 of 10 children's attendance records reviewed lacked the following required information: **Child #4 - Departure time and signature on 09/17/2024 **Child #5 - Departure time and signature on 09/05/2024 **Child #6 - Arrival and departure signatures signed with a first name and last initial only on 09/03/2024 - 09/05/2024, 09/09/2024, 09/12/2024, 09/16/2024, and 09/17/2024”

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 CO's observations and a review of facility documentation, 4 of 10 Emergency Information and Immunization Record cards reviewed lacked the following required information: **Child #1 - Parent signature **Child #2 - Health care provider name and phone number **Child #3 - Child and both parent/guardians' zip codes **Child #4 - Health care provide phone number *Previous deficiency on 09/20/2023 and 04/03/2023”

AAC R9-5-301.F. F. A licensee shall ensure that a staff member submits, on or before the starting date of employment or volunteer services, one of the following as evidence of freedom from infectious active tuberculosis: 1. Documentation of a negative Mantoux skin test or other tuberculosis screening test recommended by the U.S. Centers for Disease Control and Prevention, administered within 12 months before the starting date of employment or volunteer service, that includes the date and the type of tuberculosis screening test; or 2. If the staff member has had a positive Mantoux skin test or other tuberculosis screening test, a written statement that the staff member is free from infectious active tuberculosis that is signed and dated by a health care provider within six months before the starting date of employment or volunteer service.

“Findings: Based on CO's observations and a review of 2 staff files, Staff #1's (DOE 09/09/2024) negative tuberculosis result was dated 09/17/2024, 8 days after their starting date of employment. *Previous deficiency on 09/20/2023 and 04/03/2023”

AAC R9-5-301.B. B. A licensee shall ensure that a facility director: 1. Designates, in writing, an individual who meets the requirements of R9-5-401(2) to act on behalf of the facility director when the facility director is not present in the facility; 2. Supervises or assigns a teacher-caregiver to supervise each staff member who does not meet the qualifications of R9-5-401(3); 3. Prepares a dated attendance record for each day and ensures that each staff member documents on the attendance record the time of each arrival and departure of the staff member; and 4. Maintains on the facility premises, the dated attendance record required in subsection (B)(3) for 12 months after the date on the attendance record.

“Findings: Based on CO's observations and a review of 2 staff files, Staff #1 (DOE 09/09/2024) lacked education and experience qualifications of a teacher caregiver and was left alone, unsupervised, with enrolled children.”

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 CO's observations and a review of 2 staff files, Staff #1 (DOE 09/09/2024) lacked documentation of contact with DPS to verify Staff #1's fingerprint clearance card as valid before the starting date of employment. Staff #1's card was verified on 09/16/2024. *Previous deficiency on 09/20/2023 and 04/03/2023”

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 Compliance Officer's (CO) observations and a review of 2 staff files, Staff #1 (DOE 09/09/2024) lacked documentation of a completed DCS affidavit. *Previous deficiency 09/20/2023”

ARS § 36-883.02.C. C. Applicants, licensees and child care personnel shall attest on forms that are provided by the department that:1. They are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement committing any of the offenses listed in section 41-1758.07, subsection B in this state or similar offenses in another state or jurisdiction. 2. They are not parents or guardians of a child adjudicated to be a dependent child as defined in section 8-201. 3. They have not been denied or had revoked a certificate to operate a child care group home or a license to operate a child care facility in this or any other state or that they have not been denied or had revoked a certification to work in a child care facility or child care group home.

“Findings: Based on CO's observations and a review of 2 staff files, Staff #1 (DOE 09/09/2024) lacked documentation of a completed Criminal History Affidavit. The affidavit in the staff file was blank.”

AAC R9-5-605.B.10. B. A licensee shall ensure that:10. Toilet rooms are ventilated to the outside of the building, either by a screened window open to the outside air or by an exhaust fan and duct system that is operated when the toilet room is in use;

“Findings: Based on CO's observations, the exhaust systems in the Cafeteria Girls' and Boys' restrooms were not working.”

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 CO's observations and a review of facility documentation, Child #7's two medications were expired and had not been returned to the parent. One expired on 02/2024, and the other expired on 04/2024.”

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 CO's observations and a review of facility documentation, 1 of 2 of Child #7's medication did not match the lot number on the box that it was stored in.”

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 CO's observations, on the northwest playground, four stepping pods had exposed bolts on the top of the steps, accessible to enrolled children. *Previous deficiency on 09/20/2023 and 04/03/2023”