Y.M.C.A. - Holsclaw Family Child Care Center

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 Officers’ observations and review of documentation, the fire inspection was not current, as it was last conducted on April 11, 2024.”

AAC R9-5-305.C. C. A licensee shall attach an enrolled child’s written immunization record or exemption affidavit, required in subsection(A), to the enrolled child’s Emergency, Information, and Immunization Record, required in R9-5 304(B).

“FINDINGS: Based on the Compliance Officers’ observations, and facility documentation, it was determined that 2 out of 14 reviewed children’s files lacked the following documentation: Child 5 and Child 6: The immunization records.”

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 Compliance Officers’ observations, and facility documentation, it was determined that 5 out of 14 reviewed Emergency, Information, and Immunization Record Cards lacked the following documentation: Child 1, Child 2, Child 3, Child 4 and Child 5: The parent’s email address.”

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 child educator 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 if working with enrolled children five years old and younger, or three months of child care experience if working with school-aged children; 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 the Compliance Officers' observations and review of facility documentation, the files for Staff 1, Staff 2 and Staff 3 lacked the six months of experience to be qualified as a Child Educator.”

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’ observations, the following unrelated items were located on the diaper changing sink area: One’s classroom: An air purifier, a phone, and pens”

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’ observations, the water temperatures in the diapering sinks were out of range: One’s Room: 116F Two’s Room: 117F”

AAC R9-5-503.B. B. A licensee shall ensure that a staff member does not: 1. Permit a bottle, formula, food, eating utensil, or food preparation in a diaper changing area; 2. Draw water for human consumption from a diaper changing area sink; or 3. Change diapers until food preparation duties have been completed for the day.

“FINDINGS: Based on the Compliance Officers’ observations, the following items were located on the diaper changing sink area: One’s classroom: Drinking cups Two’s classroom: Drinking water dispenser”

AAC R9-5-503.C. C. A licensee shall ensure that a written diaper changing procedure is posted and implemented in each diaper changing area.

“FINDINGS: Based on the Compliance Officers’ observations, the One’s and Two’s classrooms lacked a written diaper changing procedure posted in the diaper changing area.”

AAC R9-5-503.E.2. E. A licensee shall ensure that in an activity area with a diaper changing area: 2. A staff member: a. Documents each diaper change with the date and time, for an: i. Infant, in the infant’s dated, daily, documentation required in R9-5-502(C)(1)(d); or ii. 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 the Compliance Officers’ observations, staff statement and review of diaper changing logs in the Two’s classroom, diaper changes were not documented for two children who were present at the time of inspection.”

AAC R9-5-504.A.3. A. A licensee providing child care services for 1-year-old and 2-year-old children shall: 3. Ensure that each activity area has a supply of age-appropriate toys, materials, and equipment that are too large for a child to swallow and free from sharp edges and points, in a quantity sufficient to meet the needs of the enrolled children in attendance including: a. Art supplies; b. Books; c. Rubber or soft plastic balls; d. Puzzles and toys to enhance manipulative skills; e. Blocks; f. Washable soft toys and dolls; g. Musical instruments; and h. Indoor and outdoor equipment to enhance large muscle development;

“FINDINGS: Based on the Compliance Officers’ observations, the Ones’ and Two’s classrooms lacked a sufficient quantity of toys and materials to meet the needs of the enrolled children.”

AAC R9-5-505.A. A. 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 Officers’ observations, the Three’s and Four’s and Five’s classrooms lacked a sufficient quantity of toys and materials to meet the needs of the enrolled children.”

AAC R9-5-509.C.17. C. A licensee shall ensure that: 17. A staff member: a. Prepares a weekly menu at least one week in advance, b. Includes on the menu the specific foods to be served on each day, c. Dates each menu, d. Posts each menu at least one day before the first meal on the menu will be served, and e. Writes food substitutions on a posted menu no later than the morning of the day of meal service;

“FINDINGS: Based on the Compliance Officers’ observations and review of documentation, the food items served on the date of inspection February 24, 2026 was the menu planned for February 26, 2026 and the substitutions were not written on the posted menu.”

AAC R9-5-512.D. D. A licensee shall ensure that toilet bowls, lavatory fixtures, and floors in toilet rooms and kitchens are cleaned and sanitized as often as necessary to maintain them in a clean and sanitized condition or at least once every 24 hours.

“FINDINGS: Based on the Compliance Officers’ observations, the toilet room in the Three’s classroom had wet toilet paper in the sink and dry toilet paper on the floor.”

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: Based on the Compliance Officers’ observations, in the Three’s classroom toilet room the paper towel dispenser lacked paper towels.”

AAC R9-5-514. E. E. 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 Officers’ observations, an evacuation plan was not posted in the Three’s classroom.”

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 Officers’ observations and review of documentation, the medication form for Child 7 did not have the end date of the dosage period.”

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 Officers’ observations and review of documentation, the prescription medication for Child 7 expired on September 20, 2025.”

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 the Compliance Officers’ observations, the toilet rooms in the following activity areas lacked operable exhaust fans: The Two’s, The Three’s and the Four’s and Five’s.”

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 child educator 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 the Compliance Officers’ observations and facility’s documentation, it was determined that Staff 1, Staff 2, and Staff 3 were working in the capacity of Child Educators, were not qualified, and were not supervised by a qualified staff member.”

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 One’s and Two’s classrooms did not have a sanitizable container with a waterproof liner and a lid for soiled clothing.”

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.

“The Compliance Officer observed the following 3 of 10 EIIR cards to be incomplete: Child 1- no date of enrollment Child 2- no date of enrollment, one emergency contact not documented, no physician information documented, and the back of the EIIR card was not completed. Child 3- no date of enrollment”

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

“The Compliance Officer observed a laminator machine accessible in the dragonfly room”

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).

“The Compliance Officer observed 3 staff files. Staff 2 did not have dates or last names of the references documented.”

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.

“The Compliance Officer observed that 2 of 3 staff were not compliant with the time frames. Staff 1 was hired 12/14/24, and the TB test results were not documented in the file. Staff 2 was hired 10/3/2024 and the TB test was read 5/31/23, not within the required time frame.”

AAC R9-5-301.I. I. At least once a month, and at different times of the day, a licensee shall ensure that an unannounced fire and emergency evacuation drill is conducted and each staff member and enrolled child at the facility participates in the fire and emergency evacuation drill. 1. If child care services for a child with special needs are provided at a facility, the licensee shall provide for the enrolled child’s participation in each fire and emergency evacuation drill according to the enrolled child’s individualized plan as specified in R9-5-507(A)(1). 2. A licensee shall document each fire and emergency evacuation drill and maintain the documentation on facility premises for 12 months after the date of the fire and emergency evacuation drill.

“The Compliance Officer observed that the staff failed to document an evacuation drill for February 2025.”

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;

“The Compliance Officer observed that the lesson plan in the Firefly room was dated 2/24- 2/28/25.”

AAC R9-5-512.C. C. A licensee shall ensure that floor coverings are:1. Clean; and 2. Free from: a. Dampness, b. Odors, and c. Hazards.

“The Compliance Officer observed the flooring and stool in the children's bathroom to have dirt and debris.”

AAC R9-5-512.D. D. A licensee shall ensure that toilet bowls, lavatory fixtures, and floors in toilet rooms and kitchens are cleaned and sanitized as often as necessary to maintain them in a clean and sanitized condition or at least once every 24 hours.

“The Compliance Officer observed the bathroom in the Dragonfly room to have urine on the toilet, and toilet paper on the toilet seat.”

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

“The Compliance Officer observed that Child 4 did not have a medication consent form for a medication maintained at the facility.”

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;

“The Compliance Officer observed that the designated emergency exit near the classrooms was blocked with brooms and a tricycle.”

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).

“The Compliance Officer observed that the graduation date was not documented on the high school transcripts for Staff 1.”

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

“The Compliance Officer observed construction materials stored in the outdoor activity area accessible to the enrolled children.”

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.

“The Compliance Officer observed that Staff 1 was hired 6/1/22, and the TB test was read negative on 7/22/22.”