10A NCAC 09 .0901 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0302 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0304 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0514 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0901 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .1003 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .1102 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .1703 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .3222 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

G.S. 110-90 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: HILL TOP HEAD START Facility ID: 20000044 Consultant: BONNIE MATHIS Operation Type: Center Case Number: Visit Date: 1/7/2026 Number Present: 13 Completed Date: 1/7/2026 Age: From 3 To 5 Total Minutes: 270 Time In: 10:00 AM Time Out: 02:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Bonnie Mathis, Licensing Supervisor, Bridget Owen, Child Care Consultant, and also signed by April DeHart, Administrator during the visit. Bridget Owen, Child Care Consultant, accompanied me during today’s visit. An electronic signed copy of the visit summary was left on-site for you. Today, April DeHart, Administrator accompanied me during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, routine caregiving activities, program records, children records and staff files. An annual compliance monitoring checklist for Child Care Center was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-nine (99%) percentage as of 01/02/2026. The North Carolina Secretary of State website was viewed prior to today’s visit and the incorporated, Four-Square Community Action, Inc. is current/active as of 12/19/2025. Permit type – Four Star License issued 1/22/2020 Special Services/Restrictions – First shift-day time care only, meets enhanced space, and meets reduced ratios. The last annual compliance visit was conducted on 1/15/2025. The last fire drill was practiced on 12/18/25. The last shelter-in-place drill was practiced on 11/21/25. The last playground inspection was documented on 12/10/25. The last fire inspection was approved on 9/22/25. The last sanitation inspection was conducted on 11/12/25 with four (4) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum, the assessment is Teaching Strategies and screening tool used is Brigance. Lead water test was completed on 8/21/23. New test required prior to August 2026. Lead paint and asbestos testing was completed on 3/31/25. Upon arrival we introduced ourselves and discussed the purpose of the visit to include documents we would need to review. There is one (1) class of fifteen (15) children enrolled 3 to 5 years of age with three (3) staff. The children were engaged in free play, appeared happy and content in their environment. Staff were up moving around and interacting with the children. For lunch the children had a cheeseburger, fries, mixed fruit and milk. There was one (1) child with a special liquid diet. There are no known allergies. 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does provide transportation. You stated that you do transport a three- and four-year-old child. I monitored two (2) vehicles today. The following violations were documented during today’s visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection was completed more than 12 months from the previous fire inspection. Fire inspection was completed on 4/2/24 and then completed on 9/2/25. The 9/2/25 fire inspection was received during today's visit and was not submitted with one (1) week of the inspection. 10A NCAC 09 .0304(a) 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Two (2) children's arrival times for today were not documented as required. 10A NCAC 09 .0302(d)(4) 525 Menus for all meals and snacks were not planned at least 1 week ahead and dated. The administrator stated food is catered in and does not know what is being served until the food arrives. Food is recorded at the time of receipt daily. Meals are not planned one week ahead. 10A NCAC 09 .0901(b) 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. Menu for lunch was not posted to be easily seen by parents. 10A NCAC 09 .0901(b) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. At the base of the slides and exit/entry points, the resilient surfacing depth measured 3 to 4 inches. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. There was a bolt protruding up from the ramp on the playground adjacent to the classroom used as the cafeteria. There are bolts protruding up around the stage and a bush with branches/limbs laying on the ground located on the large playground. There are screws protruding from the base of the toilets located in the space used as the cafeteria. 10A NCAC 09 .0601(a) 1111 All vehicles were not insured for liability as required by state law. The liability documentation on site indicated the liability effective date valid 10-01-2023 through 10-01-2024. .1002(c) 1124 Emergency and identifying information, including the child's name, photograph, emergency contact information and/or a copy of the emergency medical care information form was not in the vehicle for each child being transported. Two (2) children transported by the facility did not have a photograph and emergency medical information. 10A NCAC 09 .1003(d) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. One (1) staff member hired on 11/18/24 did not have a staff development plan. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The substitute did not have a signed and dated statement indicating receipt of operational policies. 10A NCAC 09 .0514(g) 1757 A valid qualification letter was not on file and available to review at the facility. A copy of one (1) staff member's qualification was not on-site. G.S. 110-90.2(b) & (d) & .2703(e) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A shelter in place was completed on 5/29/25 and not completed again until 11/21/25. .0604(u);.0302(d)(8) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. A staff member hired on 11/18/24 did not have a signed statement of acknowledgement prior to caring for children. The acknowledgement was dated 8/4/25. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Staff's medical confidential information was not stored separately. .0701(d) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One (1) substitute staff that was hired on 4/2/25 did not complete the training until 11/18/25. .1102(g) Technical assistance was provided as follows: Item # 106 – The fire inspection was not completed within 12 months from the previous fire inspection. To achieve compliance a statement indicating the next fire inspection will be completed no later than 9/22/26. The original fire inspection is to be submitted to your licensing consultant within one (1) week of the inspection. Item #125 – In review of the sign in and out sheet, two (2) children’s time of arrival was not documented. This was corrected during today’s visit. Item #525 & 526 – We discussed the menus and meals. You stated the food is catered in and you do not know what is being served until it arrives. We discussed to plan the meals with the caterer and creating a meal plan to ensure appropriate nutritional food is being provided to meet all food components. A menu is to be posted for easy reference for parents. To achieve compliance, describe how a menu will be planned a week in advance and posted for easy reference. Item # 716 – We discussed there was not sufficient resilient surfacing at the base of the slides and entry/exit points on the slide. We addressed there is enough dirt and wood chips to equal 6 inches; however there needs to be a minimum of 6 inches of wood chips only. We discussed there appeared to be adequate wood chips that can be shifted into these areas to provide the required 6 inches. Surfacing must be 6 inches deep from under the equipment to extend 6 feet from the furthest exit/entry of the composite structure. To achieve compliance, provide a statement explaining how adequate surfacing is maintained in all areas. Item #807 – A safe environment is required to be maintained at all times. There are bolts protruding upward on a ramp, stage and at the base of two toilets. To achieve compliance, you will need to verify the bolts have been removed or covered to remove the potential protrusion. Item #1111- The liability documentation onsite expired on 10-01-2024. To achieve compliance, provide supporting documentation or a statement indicating the date of current liability insurance and steps to prevent reoccurance. Item # 1124-A three- and four-year-old child transported daily did not have a photograph and emergency medical information on file. We discussed using the child’s application which contains all the emergency medical information required and to attach an update individual photograph. To achieve compliance, you will provide a statement indicating the required information is available and will accompany any child transported. Item #1232 – One (1) staff member did not have an annual staff development plan. To achieve compliance, provide a statement indicating the date the staff development plan was completed. Item #1233 – The substitute staff did not have a signed and dated statement indicating receipt of the facility’s operational policies. To achieve compliance, provide a copy of the operational policies to the substitute and have a signed and dated statement placed in the personnel file. Item #1757 – One (1) staff member’s criminal background qualifying letter was not on-site in their personnel file. This was corrected during the visit. Item #1811 – We discussed since the program closes beginning in June and reopens mid-August, a shelter in place and/or lockdown drill should have been completed in August To achieve compliance a statement indicating how you will ensure an emergency drill is conducted every three months is to be submitted. Item #1874 – One (1) staff did not sign acknowledgement of the Shaken Baby Syndrome policy prior to caring for children. To achieve compliance provide a statement of how the operator will ensure all staff receive the policy and reviewed prior to caring for children. Item #1890 – Staff’s medical, TB and HQ was stored together with all information within the individual’s personnel file. We discussed this information must be stored separately due to HIPPA Law requirements. To achieve compliance, you will need to create a confidential file and provide a statement indicating how compliance was achieved. Item #1897 – One (1) staff member did not complete recognizing and responding to suspicions of maltreatment within 90 days of employment as required. To achieve compliance, indicate how the operator will ensure all new staff receive the training within the first 90 days of employment. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 01/21/2026 Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: bonnie.mathis@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Bonnie Mathis, Licensing Supervisor 10 Ravenwood Lane Horseshoe, NC 28741 Please call me at 828-782-0854, or email bonnie.mathis@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Rated License Consultation: New rated license rules for Child Care Rule 3200 went into effect on 7/1/25. QRIS modernization discussion: During today’s visit an overview of section .3200 of the child care rules was provided. Each of the following pathway options were discussed: Program Assessment Pathway, Classroom and Instructional Quality Pathway, and Accreditation and Head Start Pathway. Education requirements were also reviewed. Based on today’s conversation the facility will pursue Accreditation and Head Start Pathway. We reviewed Accreditation and Head Start Pathway, along with the notice of award, staff/child ratio chart, and documentation on how all children enrolled are meeting Head Start requirements regardless of funding status. You must apply for the rated license between April to September, 2026. You may locate the rated license application on the Division’s website under provider documents. Staff education: The administrator, A. Dehart needs to apply for the administrator position in WORKS to identify administrator requirements are met. The last education evaluation was completed on 2/28/20. Ms. DeHart meets LT requirements with 26 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. C. Kitchens has NCECC + 9 SH ECE. An official transcript needs to be submitted to WORKS for education evaluation. S. Gostomski has no record in WORKS. Consultation is provided as follows: The arrival and departure policy posted in the facility is a checklist that was printed from the Division’s website. We discussed this policy is to be the center’s arrival and departure policy. The form is a checklist of the items to include within the policy. We discussed this today and you stated you will post the facility’s specific arrival and departure policy. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. One (1) substitute staff listed on the staff and training worksheet and in review of the ABCMS database has not been added to the ABCMS roster. All other staff are listed as required. We discussed an incident log is required to log all incidents that occur at the facility. You are required to use the log on the Division’s website to log all incident that require on-site first aid and off-site medical attention. You can use two separate logs to identify each or create a system that distinguishes between the two types of incidents. We discussed today, the large playground area is difficult to maintain adequate supervision, due to the layout of hidden spots. It is recommended the space is fenced off to assist with supervision and allow staff to be able to respond timely when needed. We discussed the NC Child Care Summary Law needs to be posted in a more visual area and both sides of the law must be accessible for parents and the public to view. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at bridget.owen@dhhs.nc.gov or 828.530-2424, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.