10A NCAC 09 .1102 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/23/2026 Number Present: 40 Completed Date: 4/23/2026 Age: From 5 To 10 Total Minutes: 236 Time In: 01:32 PM Time Out: 05:28 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a routine unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant. The visit summary was emailed to Delaney Burke, Senior Operations Director, for additional signature. Today, Ms. Hurlbert was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percent as of today prior to this visit. Permit type – five-star center license issued on 11/6/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The last annual compliance visit was conducted on 11/6/25. The last fire drill was practiced on 4/21/26. The last lockdown drill was practiced on 4/16/26. The Emergency Medical Care plan was posted and current. The approved curriculum is Funny Daffer. Lead water testing was completed on 6/27/24 without hazards. Lead paint was completed with no further action required by the facility. On-site is visit is pending for asbestos testing. Four (4) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I announced my presence and the purpose of the visit. Lily Elder, Program Director, met with me via TEAM and reviewed staff files. One (1) program coordinator’s file was reviewed in full, and five (5) other existing staff file was reviewed partially for criminal background letters, BSAC certificates and CPR/First Aid certificates. The program coordinator’s date of employment date is 5/14/25. However, the date of review of program’s operational and personnel policy was 1/27/23. The summary of review of Staff files are as follows: D. Hurlbert: DOE – 5/14/25 Application – 3/26/25 Orientation (2 wks & 6 wks) – 5/16/25 CBC expiration date: 5/14/30 Medical – 5/13/25 TB – 5/13/25 TB is considered incomplete due to lack of skin test. When staff member answers yes to any of the questions on the form, a follow-up skin test is also required. EI – 5/5/25 HQ – 5/5/25 Health and Safety Training – 6/11/25 CPR/First Aid – expires on 8/21/27 BSAC – 5/8/25 EMC/EPR review – 8/25/25 OP/PP/AQ review – 1/27/23 Children in group #3 were observed in the trailer. Seventeen (17) children engaged in free play with various materials, including but not limited to foam dominos, color pencils and paper, marble tower, Legos, pretend food and accessories, and games. One (1) group leader supervised the group and interacted with them. Today’s Funny Daffer activity was to create paper planes. The group leader sat with a child and folded a paper to make a paper plane. Children in group #1 played on the playground. Ten (10) children with one (1) group leader engaged in gross motor activities on the playground. One (1) large slide structure offered rock climbing, overhead ladder with triangle handles, a pole, two (2) slides, bridge and two (2) other climbers. No safety hazards were found. Children in group #2 had snacks in cafeteria. Today, BBQ links, sunflower kernels, pizza crackers, apple sauce, veggies juice blend and milk were offered. All items were accurately listed on the menu. In each approved space, staff/child was, EMC, summary of law, license, safe arrival/departure procedures were posted. Two (2) emergency medications were maintained -both epi-pen, one (1) belongs to a child in group #3 and the other to a child in group #1. One (1) of the epi-pen was not maintained in its original packet with a pharmacy label. Per interview with staff members, no other epi-pen but the two (2) I monitored has been brough in since the beginning of schoolyear. Action plans and permission forms for both Epi-pen was valid. Other licensed spaces were monitored. In the gym, various balls, flying disks, cones, tent, magnetic tiles, pretend furniture (for doll houses), Legos with wheels, marble tower, pretend animals were available for children to use. Baskets were set up in the gym for children’s personal belongings. Before leaving the facility, I went to the cafeteria to speak with a staff member regarding violations observed during today’s visit and to inform them that a copy of the visit summary would be sent to Ms. Burke. Prior to speaking with the staff member, he/she contacted a parent regarding a child’s behavior and requested that the parent pick up the child. Per interview, the staff member assigned to Group #2 stated that a child left the cafeteria unattended without his/her knowledge for approximately one (1) to two (2) minutes, until the child was brought back by elementary school personnel. The staff member reported that he/she did not know where the child had gone and was unaware the child was missing until the child was returned. Per interview with a staff member assigned to Group #3, who was present in the cafeteria at the time of the incident, the child was located by school personnel in the 2nd grade hallway. An elementary school staff member returned the child to the cafeteria. The Group #3 staff member, who was positioned near the cafeteria entrance, received the child and escorted him/her to Group #1. To access the 2nd grade hallway from the cafeteria, exit the cafeteria and turn left. Take the first right, then the first left, and proceed past the 3rd grade classrooms. The walk took approximately 54 seconds at a normal adult pace. Per interview with the staff member assigned to Group #2, he/she estimated that the child left the cafeteria while the staff member was speaking with another child regarding behavior. The behavior involved moving the child’s backpack without consent, which reportedly caused the child to become upset. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An Epi-pen for a child in group #2 was not in its original pharmacy labeled box. .0803(2)(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. TB screening for a staff member who was employed on 5/14/25 was incomplete. The TB screening completed on 5/13/25 did not have skin test results, though the staff member answered yes to one (1) of the questions. .0701(a) 1424 School-aged children were not adequately supervised. One (1) child, who was six (6) years of age, left cafeteria and traveled to the 2nd grade hallway unattended. The staff member who was responsible for this child in group #2 was unaware of the child left the group until the child was brought back to cafeteria by an elementary school personnel. The child was unattended for one (1) to two (2) minutes by estimate. .2506(d)(1-3) Technical assistance was provided as follows: 844: Medication in its original box Epi-pen for a child in group #2 was not in its original pharmacy labeled container. To comply, please obtain the original pharmacy label for P. S.’ epi-pen. If original box cannot be found, please ask pharmacy to print the label. In your compliance letter, please verify completion of this task. 1033: TB screening TB screening must be completed on or prior to first day of employment. When you use the division’s form, please note that additional skin test if required for staff members to complete when he/she/they answer yes to any of the questions listed. To comply, D. Hurlbert must complete TB skin test and submit the result to the program. In your compliance letter, please verify the completion of this task. Please do not share any medical information of any staff members via email. 1424: supervision of school-age children Children must be adequately supervised at all times. Compliance of this violation must be verified by a consultant visit. It is important to position yourself where you can see all children. While paying close attention to one (1) or a few children, position yourselves where either you block the entrance/exit and look up while talking with them. To be courteous, communicate with children and other adults that you may look around during conversation to maintain supervision of all children and to be excused. Achieving Compliance: A follow-up visit will be conducted to verify compliance of .2506(d)(1-3). 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 5/7/26. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Operational and Personnel Policies: Operational and Personnel policies shall be reviewed with each staff member at the time of employment. When staff members are re-hired after ninety (90) or more days of leave without being on a payroll, the staff is considered a new employee. All program documents, including application, orientation, review of operational/personnel/aquatics policies, training shall be completed again. Health and Safety training is valid if they were completed within twelve (12) months prior to the date of employment. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/23/2026 Number Present: 40 Completed Date: 4/23/2026 Age: From 5 To 10 Total Minutes: 236 Time In: 01:32 PM Time Out: 05:28 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a routine unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant. The visit summary was emailed to Delaney Burke, Senior Operations Director, for additional signature. Today, Ms. Hurlbert was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percent as of today prior to this visit. Permit type – five-star center license issued on 11/6/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The last annual compliance visit was conducted on 11/6/25. The last fire drill was practiced on 4/21/26. The last lockdown drill was practiced on 4/16/26. The Emergency Medical Care plan was posted and current. The approved curriculum is Funny Daffer. Lead water testing was completed on 6/27/24 without hazards. Lead paint was completed with no further action required by the facility. On-site is visit is pending for asbestos testing. Four (4) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I announced my presence and the purpose of the visit. Lily Elder, Program Director, met with me via TEAM and reviewed staff files. One (1) program coordinator’s file was reviewed in full, and five (5) other existing staff file was reviewed partially for criminal background letters, BSAC certificates and CPR/First Aid certificates. The program coordinator’s date of employment date is 5/14/25. However, the date of review of program’s operational and personnel policy was 1/27/23. The summary of review of Staff files are as follows: D. Hurlbert: DOE – 5/14/25 Application – 3/26/25 Orientation (2 wks & 6 wks) – 5/16/25 CBC expiration date: 5/14/30 Medical – 5/13/25 TB – 5/13/25 TB is considered incomplete due to lack of skin test. When staff member answers yes to any of the questions on the form, a follow-up skin test is also required. EI – 5/5/25 HQ – 5/5/25 Health and Safety Training – 6/11/25 CPR/First Aid – expires on 8/21/27 BSAC – 5/8/25 EMC/EPR review – 8/25/25 OP/PP/AQ review – 1/27/23 Children in group #3 were observed in the trailer. Seventeen (17) children engaged in free play with various materials, including but not limited to foam dominos, color pencils and paper, marble tower, Legos, pretend food and accessories, and games. One (1) group leader supervised the group and interacted with them. Today’s Funny Daffer activity was to create paper planes. The group leader sat with a child and folded a paper to make a paper plane. Children in group #1 played on the playground. Ten (10) children with one (1) group leader engaged in gross motor activities on the playground. One (1) large slide structure offered rock climbing, overhead ladder with triangle handles, a pole, two (2) slides, bridge and two (2) other climbers. No safety hazards were found. Children in group #2 had snacks in cafeteria. Today, BBQ links, sunflower kernels, pizza crackers, apple sauce, veggies juice blend and milk were offered. All items were accurately listed on the menu. In each approved space, staff/child was, EMC, summary of law, license, safe arrival/departure procedures were posted. Two (2) emergency medications were maintained -both epi-pen, one (1) belongs to a child in group #3 and the other to a child in group #1. One (1) of the epi-pen was not maintained in its original packet with a pharmacy label. Per interview with staff members, no other epi-pen but the two (2) I monitored has been brough in since the beginning of schoolyear. Action plans and permission forms for both Epi-pen was valid. Other licensed spaces were monitored. In the gym, various balls, flying disks, cones, tent, magnetic tiles, pretend furniture (for doll houses), Legos with wheels, marble tower, pretend animals were available for children to use. Baskets were set up in the gym for children’s personal belongings. Before leaving the facility, I went to the cafeteria to speak with a staff member regarding violations observed during today’s visit and to inform them that a copy of the visit summary would be sent to Ms. Burke. Prior to speaking with the staff member, he/she contacted a parent regarding a child’s behavior and requested that the parent pick up the child. Per interview, the staff member assigned to Group #2 stated that a child left the cafeteria unattended without his/her knowledge for approximately one (1) to two (2) minutes, until the child was brought back by elementary school personnel. The staff member reported that he/she did not know where the child had gone and was unaware the child was missing until the child was returned. Per interview with a staff member assigned to Group #3, who was present in the cafeteria at the time of the incident, the child was located by school personnel in the 2nd grade hallway. An elementary school staff member returned the child to the cafeteria. The Group #3 staff member, who was positioned near the cafeteria entrance, received the child and escorted him/her to Group #1. To access the 2nd grade hallway from the cafeteria, exit the cafeteria and turn left. Take the first right, then the first left, and proceed past the 3rd grade classrooms. The walk took approximately 54 seconds at a normal adult pace. Per interview with the staff member assigned to Group #2, he/she estimated that the child left the cafeteria while the staff member was speaking with another child regarding behavior. The behavior involved moving the child’s backpack without consent, which reportedly caused the child to become upset. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An Epi-pen for a child in group #2 was not in its original pharmacy labeled box. .0803(2)(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. TB screening for a staff member who was employed on 5/14/25 was incomplete. The TB screening completed on 5/13/25 did not have skin test results, though the staff member answered yes to one (1) of the questions. .0701(a) 1424 School-aged children were not adequately supervised. One (1) child, who was six (6) years of age, left cafeteria and traveled to the 2nd grade hallway unattended. The staff member who was responsible for this child in group #2 was unaware of the child left the group until the child was brought back to cafeteria by an elementary school personnel. The child was unattended for one (1) to two (2) minutes by estimate. .2506(d)(1-3) Technical assistance was provided as follows: 844: Medication in its original box Epi-pen for a child in group #2 was not in its original pharmacy labeled container. To comply, please obtain the original pharmacy label for P. S.’ epi-pen. If original box cannot be found, please ask pharmacy to print the label. In your compliance letter, please verify completion of this task. 1033: TB screening TB screening must be completed on or prior to first day of employment. When you use the division’s form, please note that additional skin test if required for staff members to complete when he/she/they answer yes to any of the questions listed. To comply, D. Hurlbert must complete TB skin test and submit the result to the program. In your compliance letter, please verify the completion of this task. Please do not share any medical information of any staff members via email. 1424: supervision of school-age children Children must be adequately supervised at all times. Compliance of this violation must be verified by a consultant visit. It is important to position yourself where you can see all children. While paying close attention to one (1) or a few children, position yourselves where either you block the entrance/exit and look up while talking with them. To be courteous, communicate with children and other adults that you may look around during conversation to maintain supervision of all children and to be excused. Achieving Compliance: A follow-up visit will be conducted to verify compliance of .2506(d)(1-3). 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 5/7/26. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Operational and Personnel Policies: Operational and Personnel policies shall be reviewed with each staff member at the time of employment. When staff members are re-hired after ninety (90) or more days of leave without being on a payroll, the staff is considered a new employee. All program documents, including application, orientation, review of operational/personnel/aquatics policies, training shall be completed again. Health and Safety training is valid if they were completed within twelve (12) months prior to the date of employment. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .3222 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/23/2026 Number Present: 40 Completed Date: 4/23/2026 Age: From 5 To 10 Total Minutes: 236 Time In: 01:32 PM Time Out: 05:28 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a routine unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant. The visit summary was emailed to Delaney Burke, Senior Operations Director, for additional signature. Today, Ms. Hurlbert was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percent as of today prior to this visit. Permit type – five-star center license issued on 11/6/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The last annual compliance visit was conducted on 11/6/25. The last fire drill was practiced on 4/21/26. The last lockdown drill was practiced on 4/16/26. The Emergency Medical Care plan was posted and current. The approved curriculum is Funny Daffer. Lead water testing was completed on 6/27/24 without hazards. Lead paint was completed with no further action required by the facility. On-site is visit is pending for asbestos testing. Four (4) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I announced my presence and the purpose of the visit. Lily Elder, Program Director, met with me via TEAM and reviewed staff files. One (1) program coordinator’s file was reviewed in full, and five (5) other existing staff file was reviewed partially for criminal background letters, BSAC certificates and CPR/First Aid certificates. The program coordinator’s date of employment date is 5/14/25. However, the date of review of program’s operational and personnel policy was 1/27/23. The summary of review of Staff files are as follows: D. Hurlbert: DOE – 5/14/25 Application – 3/26/25 Orientation (2 wks & 6 wks) – 5/16/25 CBC expiration date: 5/14/30 Medical – 5/13/25 TB – 5/13/25 TB is considered incomplete due to lack of skin test. When staff member answers yes to any of the questions on the form, a follow-up skin test is also required. EI – 5/5/25 HQ – 5/5/25 Health and Safety Training – 6/11/25 CPR/First Aid – expires on 8/21/27 BSAC – 5/8/25 EMC/EPR review – 8/25/25 OP/PP/AQ review – 1/27/23 Children in group #3 were observed in the trailer. Seventeen (17) children engaged in free play with various materials, including but not limited to foam dominos, color pencils and paper, marble tower, Legos, pretend food and accessories, and games. One (1) group leader supervised the group and interacted with them. Today’s Funny Daffer activity was to create paper planes. The group leader sat with a child and folded a paper to make a paper plane. Children in group #1 played on the playground. Ten (10) children with one (1) group leader engaged in gross motor activities on the playground. One (1) large slide structure offered rock climbing, overhead ladder with triangle handles, a pole, two (2) slides, bridge and two (2) other climbers. No safety hazards were found. Children in group #2 had snacks in cafeteria. Today, BBQ links, sunflower kernels, pizza crackers, apple sauce, veggies juice blend and milk were offered. All items were accurately listed on the menu. In each approved space, staff/child was, EMC, summary of law, license, safe arrival/departure procedures were posted. Two (2) emergency medications were maintained -both epi-pen, one (1) belongs to a child in group #3 and the other to a child in group #1. One (1) of the epi-pen was not maintained in its original packet with a pharmacy label. Per interview with staff members, no other epi-pen but the two (2) I monitored has been brough in since the beginning of schoolyear. Action plans and permission forms for both Epi-pen was valid. Other licensed spaces were monitored. In the gym, various balls, flying disks, cones, tent, magnetic tiles, pretend furniture (for doll houses), Legos with wheels, marble tower, pretend animals were available for children to use. Baskets were set up in the gym for children’s personal belongings. Before leaving the facility, I went to the cafeteria to speak with a staff member regarding violations observed during today’s visit and to inform them that a copy of the visit summary would be sent to Ms. Burke. Prior to speaking with the staff member, he/she contacted a parent regarding a child’s behavior and requested that the parent pick up the child. Per interview, the staff member assigned to Group #2 stated that a child left the cafeteria unattended without his/her knowledge for approximately one (1) to two (2) minutes, until the child was brought back by elementary school personnel. The staff member reported that he/she did not know where the child had gone and was unaware the child was missing until the child was returned. Per interview with a staff member assigned to Group #3, who was present in the cafeteria at the time of the incident, the child was located by school personnel in the 2nd grade hallway. An elementary school staff member returned the child to the cafeteria. The Group #3 staff member, who was positioned near the cafeteria entrance, received the child and escorted him/her to Group #1. To access the 2nd grade hallway from the cafeteria, exit the cafeteria and turn left. Take the first right, then the first left, and proceed past the 3rd grade classrooms. The walk took approximately 54 seconds at a normal adult pace. Per interview with the staff member assigned to Group #2, he/she estimated that the child left the cafeteria while the staff member was speaking with another child regarding behavior. The behavior involved moving the child’s backpack without consent, which reportedly caused the child to become upset. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An Epi-pen for a child in group #2 was not in its original pharmacy labeled box. .0803(2)(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. TB screening for a staff member who was employed on 5/14/25 was incomplete. The TB screening completed on 5/13/25 did not have skin test results, though the staff member answered yes to one (1) of the questions. .0701(a) 1424 School-aged children were not adequately supervised. One (1) child, who was six (6) years of age, left cafeteria and traveled to the 2nd grade hallway unattended. The staff member who was responsible for this child in group #2 was unaware of the child left the group until the child was brought back to cafeteria by an elementary school personnel. The child was unattended for one (1) to two (2) minutes by estimate. .2506(d)(1-3) Technical assistance was provided as follows: 844: Medication in its original box Epi-pen for a child in group #2 was not in its original pharmacy labeled container. To comply, please obtain the original pharmacy label for P. S.’ epi-pen. If original box cannot be found, please ask pharmacy to print the label. In your compliance letter, please verify completion of this task. 1033: TB screening TB screening must be completed on or prior to first day of employment. When you use the division’s form, please note that additional skin test if required for staff members to complete when he/she/they answer yes to any of the questions listed. To comply, D. Hurlbert must complete TB skin test and submit the result to the program. In your compliance letter, please verify the completion of this task. Please do not share any medical information of any staff members via email. 1424: supervision of school-age children Children must be adequately supervised at all times. Compliance of this violation must be verified by a consultant visit. It is important to position yourself where you can see all children. While paying close attention to one (1) or a few children, position yourselves where either you block the entrance/exit and look up while talking with them. To be courteous, communicate with children and other adults that you may look around during conversation to maintain supervision of all children and to be excused. Achieving Compliance: A follow-up visit will be conducted to verify compliance of .2506(d)(1-3). 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 5/7/26. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Operational and Personnel Policies: Operational and Personnel policies shall be reviewed with each staff member at the time of employment. When staff members are re-hired after ninety (90) or more days of leave without being on a payroll, the staff is considered a new employee. All program documents, including application, orientation, review of operational/personnel/aquatics policies, training shall be completed again. Health and Safety training is valid if they were completed within twelve (12) months prior to the date of employment. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

NC GS 110-90 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/23/2026 Number Present: 40 Completed Date: 4/23/2026 Age: From 5 To 10 Total Minutes: 236 Time In: 01:32 PM Time Out: 05:28 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a routine unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant. The visit summary was emailed to Delaney Burke, Senior Operations Director, for additional signature. Today, Ms. Hurlbert was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percent as of today prior to this visit. Permit type – five-star center license issued on 11/6/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The last annual compliance visit was conducted on 11/6/25. The last fire drill was practiced on 4/21/26. The last lockdown drill was practiced on 4/16/26. The Emergency Medical Care plan was posted and current. The approved curriculum is Funny Daffer. Lead water testing was completed on 6/27/24 without hazards. Lead paint was completed with no further action required by the facility. On-site is visit is pending for asbestos testing. Four (4) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I announced my presence and the purpose of the visit. Lily Elder, Program Director, met with me via TEAM and reviewed staff files. One (1) program coordinator’s file was reviewed in full, and five (5) other existing staff file was reviewed partially for criminal background letters, BSAC certificates and CPR/First Aid certificates. The program coordinator’s date of employment date is 5/14/25. However, the date of review of program’s operational and personnel policy was 1/27/23. The summary of review of Staff files are as follows: D. Hurlbert: DOE – 5/14/25 Application – 3/26/25 Orientation (2 wks & 6 wks) – 5/16/25 CBC expiration date: 5/14/30 Medical – 5/13/25 TB – 5/13/25 TB is considered incomplete due to lack of skin test. When staff member answers yes to any of the questions on the form, a follow-up skin test is also required. EI – 5/5/25 HQ – 5/5/25 Health and Safety Training – 6/11/25 CPR/First Aid – expires on 8/21/27 BSAC – 5/8/25 EMC/EPR review – 8/25/25 OP/PP/AQ review – 1/27/23 Children in group #3 were observed in the trailer. Seventeen (17) children engaged in free play with various materials, including but not limited to foam dominos, color pencils and paper, marble tower, Legos, pretend food and accessories, and games. One (1) group leader supervised the group and interacted with them. Today’s Funny Daffer activity was to create paper planes. The group leader sat with a child and folded a paper to make a paper plane. Children in group #1 played on the playground. Ten (10) children with one (1) group leader engaged in gross motor activities on the playground. One (1) large slide structure offered rock climbing, overhead ladder with triangle handles, a pole, two (2) slides, bridge and two (2) other climbers. No safety hazards were found. Children in group #2 had snacks in cafeteria. Today, BBQ links, sunflower kernels, pizza crackers, apple sauce, veggies juice blend and milk were offered. All items were accurately listed on the menu. In each approved space, staff/child was, EMC, summary of law, license, safe arrival/departure procedures were posted. Two (2) emergency medications were maintained -both epi-pen, one (1) belongs to a child in group #3 and the other to a child in group #1. One (1) of the epi-pen was not maintained in its original packet with a pharmacy label. Per interview with staff members, no other epi-pen but the two (2) I monitored has been brough in since the beginning of schoolyear. Action plans and permission forms for both Epi-pen was valid. Other licensed spaces were monitored. In the gym, various balls, flying disks, cones, tent, magnetic tiles, pretend furniture (for doll houses), Legos with wheels, marble tower, pretend animals were available for children to use. Baskets were set up in the gym for children’s personal belongings. Before leaving the facility, I went to the cafeteria to speak with a staff member regarding violations observed during today’s visit and to inform them that a copy of the visit summary would be sent to Ms. Burke. Prior to speaking with the staff member, he/she contacted a parent regarding a child’s behavior and requested that the parent pick up the child. Per interview, the staff member assigned to Group #2 stated that a child left the cafeteria unattended without his/her knowledge for approximately one (1) to two (2) minutes, until the child was brought back by elementary school personnel. The staff member reported that he/she did not know where the child had gone and was unaware the child was missing until the child was returned. Per interview with a staff member assigned to Group #3, who was present in the cafeteria at the time of the incident, the child was located by school personnel in the 2nd grade hallway. An elementary school staff member returned the child to the cafeteria. The Group #3 staff member, who was positioned near the cafeteria entrance, received the child and escorted him/her to Group #1. To access the 2nd grade hallway from the cafeteria, exit the cafeteria and turn left. Take the first right, then the first left, and proceed past the 3rd grade classrooms. The walk took approximately 54 seconds at a normal adult pace. Per interview with the staff member assigned to Group #2, he/she estimated that the child left the cafeteria while the staff member was speaking with another child regarding behavior. The behavior involved moving the child’s backpack without consent, which reportedly caused the child to become upset. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An Epi-pen for a child in group #2 was not in its original pharmacy labeled box. .0803(2)(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. TB screening for a staff member who was employed on 5/14/25 was incomplete. The TB screening completed on 5/13/25 did not have skin test results, though the staff member answered yes to one (1) of the questions. .0701(a) 1424 School-aged children were not adequately supervised. One (1) child, who was six (6) years of age, left cafeteria and traveled to the 2nd grade hallway unattended. The staff member who was responsible for this child in group #2 was unaware of the child left the group until the child was brought back to cafeteria by an elementary school personnel. The child was unattended for one (1) to two (2) minutes by estimate. .2506(d)(1-3) Technical assistance was provided as follows: 844: Medication in its original box Epi-pen for a child in group #2 was not in its original pharmacy labeled container. To comply, please obtain the original pharmacy label for P. S.’ epi-pen. If original box cannot be found, please ask pharmacy to print the label. In your compliance letter, please verify completion of this task. 1033: TB screening TB screening must be completed on or prior to first day of employment. When you use the division’s form, please note that additional skin test if required for staff members to complete when he/she/they answer yes to any of the questions listed. To comply, D. Hurlbert must complete TB skin test and submit the result to the program. In your compliance letter, please verify the completion of this task. Please do not share any medical information of any staff members via email. 1424: supervision of school-age children Children must be adequately supervised at all times. Compliance of this violation must be verified by a consultant visit. It is important to position yourself where you can see all children. While paying close attention to one (1) or a few children, position yourselves where either you block the entrance/exit and look up while talking with them. To be courteous, communicate with children and other adults that you may look around during conversation to maintain supervision of all children and to be excused. Achieving Compliance: A follow-up visit will be conducted to verify compliance of .2506(d)(1-3). 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 5/7/26. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Operational and Personnel Policies: Operational and Personnel policies shall be reviewed with each staff member at the time of employment. When staff members are re-hired after ninety (90) or more days of leave without being on a payroll, the staff is considered a new employee. All program documents, including application, orientation, review of operational/personnel/aquatics policies, training shall be completed again. Health and Safety training is valid if they were completed within twelve (12) months prior to the date of employment. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .0304 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .1703 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .3222 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

G.S. 110-90 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

NC GS 110-90 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/6/2025 Number Present: 39 Completed Date: 11/6/2025 Age: From 5 To 10 Total Minutes: 195 Time In: 01:00 PM Time Out: 04:15 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 visit A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins Child Care Consultant and also signed by Ryleigh Spoonholtz, Substitute Program Coordinator, during the visit. Bridget Owen, Child Care Consultant accompanied me during today’s visit. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Operations Director. Today, Ms. Spoonholtz was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers 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-three (93) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 11/3/25. Permit type – five-star center license issued on 5/21/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The following restriction will be removed from the permit: Plygrd. area does not meet cc plygrd. safety standards. Children are prohibited from being in the kitchen for any purpose. This was discussed with Ms. Spoonholtz during the visit. The last annual compliance visit was conducted on 11/15/25. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. The Emergency Medical Care plan was posted but not current. Individuals responsible for First Aid and CPR were not listed, and one (1) of the staff listed was on long-term leave. Lead water testing was completed on 6/27/24 without hazards. On-site results are pending for lead paint and asbestos testing. Upon arrival, we looked for a Program Coordinator in space #4, but no one was present. According to the Staff and Training Worksheet, Ms. Spoonholtz is listed as the substitute Program Coordinator with work hours from 1:00 p.m. to 6:00 p.m. To remain unannounced, no administrative staff members were contacted until 1:43 p.m., when Ms. Spoonholtz arrived. During the observation, I observed the arrival process for the school-age children in Groups One (1), Two (2), and Three (3). All children were signed in both electronically and on a paper sign-in sheet. The Group Leader for Group One (1) engaged the children in an activity while waiting for nine (9) children to arrive. The Group Leader for Group Three (3) interacted with children from both Group Two (2) and Group Three (3) during arrival and sign-in. Once all children were accounted for, the three groups separated. I monitored Group One (1) as they transitioned to the bathroom to wash their hands in preparation for their afternoon snack. Supervision was observed to be appropriate and consistent throughout the transition. Teacher-child interactions were positive and age-appropriate, with no concerns observed in this area. Snacks were provided. The children had sunflower kernels, veggie blend juice, WG crackers, BBQ Jack links, apple sauce and milk. The items were accurately listed on the menu. The Staff and Training Worksheet was reviewed via a TEAMS meeting with Ms. Burke. The staff files for F. Grady and H. Ramsey had already been reviewed during the annual compliance visit for YMCA W.W. Estes Afterschool conducted on October 16, 2025; therefore, those files were not reviewed during today’s visit. H. Ramsey, Program Director, was not listed on the Staff and Training Worksheet. I requested that Ms. Burke submit an updated Staff and Training Worksheet to include H. Ramsey. Several dates were edited on the Staff and Training Worksheet based on file review. According to Ms. Delaney, “Super Saturday SEL and Service Learning” counted for on-going training hours for R. Spoonholtz and J. Cauffield was entered as two (2) hours of training in their system; however, it was an all-day training and should count for eight (8) hours instead. Most staff members complete the Health and Safety training annually. However, on the Staff and Training Worksheet, the date listed for Health and Safety training should reflect either the initial completion date or the fifth-year renewal date, as only those instances meet the regulatory requirement. Health and Safety training completed in between those required years may still be counted toward ongoing training hours, but not as the required Health and Safety training date. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 not provide transportation. YMCA buses were inspected on June 4, 2025. The following violations were documented during today’s visit: Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. The last fire drill was practiced on 10/28/25. The drill prior to 10/28/25 was conducted on 8/29/25. .0604(t); .0302(d)(5) 838 The EMC plan did not name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. Neither staff members listed for accompanying the ill/injured person were not on-site during today's visit. No staff members were listed for person/alternate person to administer first aid and CPR. .0802(a)(2)(A-D) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. An epi-pen for a child was not in its original box with a pharmacy label. .0803(2)(a) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. No staff member was listed on the roster for this program on the ABCMS site as of today. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last lockdown drill was practiced on 10/29/25. The drill prior to 10/29/25 was conducted on 6/6/25. .0604(u);.0302(d)(8) Technical assistance was provided as follows: 805: Fire drill September fire drill was either not conducted or not logged. Please conduct a fire drill each month and document all required information. To comply, you must conduct a fire drill to make up for September drill. On the log sheet, please document the actual date you completed the drill and note “in-place for September”. You must conduct this drill in-place for September; therefore, it will not count for November drill. You must conduct a separate drill for September. 1811: Shelter-in-place/lockdown drill A shelter-in-place or a lockdown drill is required be conducted within the first ten (10) days of school if it is closed during summer and every three (3) months thereafter. Per Emergency log, a shelter-in-place drill was conducted on June 6, 2025, then October 29, 2025. You did not conduct a drill in September within ten (10) days of school start. Since you conducted a lockdown drill, it will count in place for September drill and this violation is marked corrected during the visit. However, you must complete a shelter-in-place or a lockdown drill in December 2025. 838: Emergency Medical Care (EMC) Plan The EMC plan must name the person responsible for taking the authorization for treatment, accompanying the ill or injured person, notifying contact persons and/or obtaining substitutes. The person responsible or alternate who administer first aid/CPR were not written on the EMC plan. To comply, please add additional people on the EMC plan for items #7 and 8. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 844: Original box Prescription medication must be maintained in its original box with a pharmacy label to make sure that the medication is prescribed to a correct child. Before administering the medication, staff members must verify 5Rs – right child, right medication, right route, right time and right dosage. To comply, please ask parents to bring the original box for the medication. If it is not possible, ask him/her to request a pharmacy label from the pharmacy for the medication. In your compliance letter, please state the action you took to meet compliance. 1805: ABCMS roster 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. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. To comply, please take the training on the DCDEE Moodle first and follow the procedures for listing all staff members. 1914: EMC The person identified as the person or alternate person responsible for carrying out the emergency medical care plan shall be on the premises at all times and accompany children for off premise activities. Neither staff member (a person responsible and an alternate) listed as responsible for carrying out the emergency medical care plan were present at the facility. To comply, please list staff members who are present on-site most of the time for items 7, 8 and 11. In your compliance letter, you can send me updated copy of the EMC or state the action you took to meet compliance. 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 11/20/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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. Consultation is provided as follows: Rated License Assessment is not due for this program until May 2028. Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. 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. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .0510 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/21/2025 Number Present: 39 Completed Date: 5/21/2025 Age: From 5 To 10 Total Minutes: 180 Time In: 02:00 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: ERS Announced/Unannounced: Announced The purpose of today’s announced visit was to review the results of your Environment Rating Scale assessment and to finalize your rated license assessment. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant and also signed by Sora Dowty, Program Coordinator, during the visit. A signed copy of the visit summary was electronically emailed to Delaney Burke, Senior Operations Director. Lily Elder, Program Director, was on-site and available to answer and ask questions. The program operates with a three-star center license issued on 1/25/23. The special restrictions include daytime care, school-age only, meets enhanced space and reduced ratios. The playground area does not meet child care playground safety standards. Children are prohibited in the kitchen for any purpose. SACERS-U was conducted on 4/30/25. The Rated License Assessment visit was conducted on 5/5/25 and scored 5. Upon arrival, I announced my presence and the purpose of the visit. All items scoring four (4) points and under were discussed with the Environment Rating Scale (ERS) Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today. There was a total of twenty (27) children present, and thirty-three (33) children enrolled. One (1) existing staff file was reviewed for updated CPR and First Aid certificate. The Child Care Center Item Number Listing (DCDEE-0357) was used as a basic monitoring tool to assess compliance with applicable child care requirements pertinent to this facility. The following items were reviewed for SACERS-U assessment: Item 2- 5.1 & 5.2: Outdoor play must be provided to the children on a daily basis whether permitted. Outdoor requirements do not apply to the program. Per interview with Ms. Elder, there may have been a language barrier on how a staff member responded to the interview question. Ms. Elder stated that children in this program goes outside on a daily basis with reasonable adjustments based on weather and children’s needs. Item 14 – 3.1: The loose surfacing is not required for this program per licensing restrictions. Item 17- 3.5: tables must be cleaned with soapy water and bleach solutions appropriately prior to each meal. This may be a violation of 15A NCAC 18A.2822(a)(1-4). Tables were cleaned with soapy water and sanitizing solutions prior to children’s arrival during the visit. Item 18 – 5.1: Handwashing shall be conducted appropriately. Per 15A NCAC 18A.2803(c), Children shall wash their hands upon arrival at the center, after each visit to the toilet, before eating, and before and after water play, after outside play, and/or after handling animals or animal cages. Additionally, 15A NCAC 18A.2803(a) states that Staff shall wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Upon arrival, children put their backpacks in the basket and gathered on a specific section in the cafeteria. Most children read books and talked with friends while all the children arrived. One (1) child moved to the tables where the materials were set up and played with toy animals, and one (1) child sat in the quiet area (individual tent) for appropriately five (5) minutes. When all the children arrived, the group lined up, went to the gym and used the bathroom to wash their hands. The materials used prior to handwashing were not moved. Item 18 – 5.2: lavatories must be kept clean per 15A NCAC 18A.2818(a). Per interview with staff members, the bathrooms are cleaned daily by the school custodians. I observed some paper towels on the floor. However, it was not possible for the group leaders to go into the bathroom and clean the bathroom as well as supervising the children. Item 20 – 5.1 and 5.2: Music and rhythm activities must be available weekly per 10A NCAC 09 .0510(c)(1). However, the types of musical instruments and the props are not a part of licensing requirements. Per Ms. Elder, music and rhythm materials are maintained in the cabinet and available for use weekly. No musical instruments were accessible to the children during the visit. Item 21 – 5.3: This is not a licensing requirement. Item 22 – 5.2: This is not a licensing requirement. However, extending child’s play nurture children’s creativity and approaches learning. Item 23- 5.1: This is not a licensing requirement. Item 23 – 5.2: This is not a licensing requirement. However, reading to children are important part of language and literacy development. The staff members should provide reading opportunities frequently. Per Ms. Elder, the program uses Kidz-Lit curriculum. This is the literacy curriculum where children and staff read a book followed by related activities and discussions over several days. Though the reading activity is not offered daily, the activities for Kidz-Lit is based on the reading and enriches overall literacy activities. Item 23 -5.3: Daily activity shall be designed to stimulate language development and communication per .0508(b)(1-5). Children in group #2 engages in group discussion upon arrival while children in group #1 uses the bathroom. Additionally, various games and books are accessible to the children daily. Apple to Apple Junior, Spapzi, Spot it! games were accessible to the children during today’s visit. Item 24 – 5.2: Daily activity shall be designed to stimulate cognitive development per .0508(b)(1-5). During the visit, I observed math related play materials, such as Plus Plus Blocks, Buildzi puzzles, chess, uno dominos and magnetic tiles. Item 25 – 3.2: Science and nature activities must be available weekly per .0510(c)(2). I observed one (1) children brought Red Clover plants and talked about it with other children. There were Science viewer kit and 3D insect specimens were accessible to the children during the visit. Item 29 – 5.4: even though this is not a licensing requirements, open-ended questions are effective ways to promote critical thinking. Item 36 – 5.3: for the program offers five (5) hours or less per day, a minimum of thirty (30) minutes of outdoor time is required weather permitted, per .0508(c). Both children in group #1 and group #2 played on the playground during today’s visit. The following violations of child care requirements observed: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. The program's safe arrival/departure policy was posted in the cafeteria. Per policy, the parents are expected to enter the facility and sign out of the children. However, the current procedure for this program is to sign in/out of the children using Daxko apps. .1003(b) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A container of Vomit Control was located on the table in the cafeteria. .2820(b) Technical assistance for correction plan: 801: Safe pick-up procedures must be established and followed, per .1003(b). The procedures of arrival/departure posted on site did not match the current practice using Daxko app. This item was corrected during the visit. Refer to 10A NCAC 09 .1003(b). 840: Potentially hazardous item A container of Vomit Control was found on the table on the corner of cafeteria being accessible to the children. The container was removed during the visit. Refer to 15A NCAC 18A.2820(b). Achieving Compliance: Due to all violations being corrected during the visit, you are not required to submit a letter of compliance. Please continue to maintain the compliance. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Rated License Assessment: Compliance History: The program must maintain a 75% or higher compliance history score to be eligible for a 2-5 star rated license. The compliance history for the facility prior to the visit today was ninety-five (95) percent. Staff Education: It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submitted an official transcript (if applicable) and applied 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. Staff education and experience is under review. Program Standards: Program Standards: I reviewed the requirements for .2806. Based on the schedule, lesson plans and room set up in space #4, creative activities, cultural activities, games/manipulatives, homework time, reading activities, social skills/life skills/problem solving activities and structured/unstructured physical activities are offered to children daily. The program follows enhanced space and reduced ratios, and the SACERS-U score was 5.03. Based on the information above, the program points for the program is expected to be seven (7) points. Quality Point: A quality point is met by meeting requirements for the staff benefits package(vacation, sick time, retirement, and health insurance) and infrastructure of parent involvement (quarterly newsletter and periodic conferences for all children). Quality Point = 1 point. Total points will be determined after education is evaluated. After final review, points under each component may change. The centers rated license assessment is due once every three years based on the date of the completed Environment Rating Scale scores, if applicable. During the three-year reassessment, the center’s program standards, staff education and a quality point option are determined to award the center’s star level. It is the center operator’s responsibility to maintain the same point level under each component at all times. If changes occur that may affect your rated license, please notify your licensing consultant to inform her of the changes and discuss a plan of action to maintain the center’s star rating. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a) A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. Consultation: We discussed staff member’s WORKS letters during the visit. 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 licensing 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 as needed. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. Please continue to visit DCDEE’s website to get the latest COVID-19 information for child care at https://ncchildcare.ncdhhs.gov/. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/21/2025 Number Present: 39 Completed Date: 5/21/2025 Age: From 5 To 10 Total Minutes: 180 Time In: 02:00 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: ERS Announced/Unannounced: Announced The purpose of today’s announced visit was to review the results of your Environment Rating Scale assessment and to finalize your rated license assessment. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant and also signed by Sora Dowty, Program Coordinator, during the visit. A signed copy of the visit summary was electronically emailed to Delaney Burke, Senior Operations Director. Lily Elder, Program Director, was on-site and available to answer and ask questions. The program operates with a three-star center license issued on 1/25/23. The special restrictions include daytime care, school-age only, meets enhanced space and reduced ratios. The playground area does not meet child care playground safety standards. Children are prohibited in the kitchen for any purpose. SACERS-U was conducted on 4/30/25. The Rated License Assessment visit was conducted on 5/5/25 and scored 5. Upon arrival, I announced my presence and the purpose of the visit. All items scoring four (4) points and under were discussed with the Environment Rating Scale (ERS) Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today. There was a total of twenty (27) children present, and thirty-three (33) children enrolled. One (1) existing staff file was reviewed for updated CPR and First Aid certificate. The Child Care Center Item Number Listing (DCDEE-0357) was used as a basic monitoring tool to assess compliance with applicable child care requirements pertinent to this facility. The following items were reviewed for SACERS-U assessment: Item 2- 5.1 & 5.2: Outdoor play must be provided to the children on a daily basis whether permitted. Outdoor requirements do not apply to the program. Per interview with Ms. Elder, there may have been a language barrier on how a staff member responded to the interview question. Ms. Elder stated that children in this program goes outside on a daily basis with reasonable adjustments based on weather and children’s needs. Item 14 – 3.1: The loose surfacing is not required for this program per licensing restrictions. Item 17- 3.5: tables must be cleaned with soapy water and bleach solutions appropriately prior to each meal. This may be a violation of 15A NCAC 18A.2822(a)(1-4). Tables were cleaned with soapy water and sanitizing solutions prior to children’s arrival during the visit. Item 18 – 5.1: Handwashing shall be conducted appropriately. Per 15A NCAC 18A.2803(c), Children shall wash their hands upon arrival at the center, after each visit to the toilet, before eating, and before and after water play, after outside play, and/or after handling animals or animal cages. Additionally, 15A NCAC 18A.2803(a) states that Staff shall wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Upon arrival, children put their backpacks in the basket and gathered on a specific section in the cafeteria. Most children read books and talked with friends while all the children arrived. One (1) child moved to the tables where the materials were set up and played with toy animals, and one (1) child sat in the quiet area (individual tent) for appropriately five (5) minutes. When all the children arrived, the group lined up, went to the gym and used the bathroom to wash their hands. The materials used prior to handwashing were not moved. Item 18 – 5.2: lavatories must be kept clean per 15A NCAC 18A.2818(a). Per interview with staff members, the bathrooms are cleaned daily by the school custodians. I observed some paper towels on the floor. However, it was not possible for the group leaders to go into the bathroom and clean the bathroom as well as supervising the children. Item 20 – 5.1 and 5.2: Music and rhythm activities must be available weekly per 10A NCAC 09 .0510(c)(1). However, the types of musical instruments and the props are not a part of licensing requirements. Per Ms. Elder, music and rhythm materials are maintained in the cabinet and available for use weekly. No musical instruments were accessible to the children during the visit. Item 21 – 5.3: This is not a licensing requirement. Item 22 – 5.2: This is not a licensing requirement. However, extending child’s play nurture children’s creativity and approaches learning. Item 23- 5.1: This is not a licensing requirement. Item 23 – 5.2: This is not a licensing requirement. However, reading to children are important part of language and literacy development. The staff members should provide reading opportunities frequently. Per Ms. Elder, the program uses Kidz-Lit curriculum. This is the literacy curriculum where children and staff read a book followed by related activities and discussions over several days. Though the reading activity is not offered daily, the activities for Kidz-Lit is based on the reading and enriches overall literacy activities. Item 23 -5.3: Daily activity shall be designed to stimulate language development and communication per .0508(b)(1-5). Children in group #2 engages in group discussion upon arrival while children in group #1 uses the bathroom. Additionally, various games and books are accessible to the children daily. Apple to Apple Junior, Spapzi, Spot it! games were accessible to the children during today’s visit. Item 24 – 5.2: Daily activity shall be designed to stimulate cognitive development per .0508(b)(1-5). During the visit, I observed math related play materials, such as Plus Plus Blocks, Buildzi puzzles, chess, uno dominos and magnetic tiles. Item 25 – 3.2: Science and nature activities must be available weekly per .0510(c)(2). I observed one (1) children brought Red Clover plants and talked about it with other children. There were Science viewer kit and 3D insect specimens were accessible to the children during the visit. Item 29 – 5.4: even though this is not a licensing requirements, open-ended questions are effective ways to promote critical thinking. Item 36 – 5.3: for the program offers five (5) hours or less per day, a minimum of thirty (30) minutes of outdoor time is required weather permitted, per .0508(c). Both children in group #1 and group #2 played on the playground during today’s visit. The following violations of child care requirements observed: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. The program's safe arrival/departure policy was posted in the cafeteria. Per policy, the parents are expected to enter the facility and sign out of the children. However, the current procedure for this program is to sign in/out of the children using Daxko apps. .1003(b) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A container of Vomit Control was located on the table in the cafeteria. .2820(b) Technical assistance for correction plan: 801: Safe pick-up procedures must be established and followed, per .1003(b). The procedures of arrival/departure posted on site did not match the current practice using Daxko app. This item was corrected during the visit. Refer to 10A NCAC 09 .1003(b). 840: Potentially hazardous item A container of Vomit Control was found on the table on the corner of cafeteria being accessible to the children. The container was removed during the visit. Refer to 15A NCAC 18A.2820(b). Achieving Compliance: Due to all violations being corrected during the visit, you are not required to submit a letter of compliance. Please continue to maintain the compliance. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Rated License Assessment: Compliance History: The program must maintain a 75% or higher compliance history score to be eligible for a 2-5 star rated license. The compliance history for the facility prior to the visit today was ninety-five (95) percent. Staff Education: It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submitted an official transcript (if applicable) and applied 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. Staff education and experience is under review. Program Standards: Program Standards: I reviewed the requirements for .2806. Based on the schedule, lesson plans and room set up in space #4, creative activities, cultural activities, games/manipulatives, homework time, reading activities, social skills/life skills/problem solving activities and structured/unstructured physical activities are offered to children daily. The program follows enhanced space and reduced ratios, and the SACERS-U score was 5.03. Based on the information above, the program points for the program is expected to be seven (7) points. Quality Point: A quality point is met by meeting requirements for the staff benefits package(vacation, sick time, retirement, and health insurance) and infrastructure of parent involvement (quarterly newsletter and periodic conferences for all children). Quality Point = 1 point. Total points will be determined after education is evaluated. After final review, points under each component may change. The centers rated license assessment is due once every three years based on the date of the completed Environment Rating Scale scores, if applicable. During the three-year reassessment, the center’s program standards, staff education and a quality point option are determined to award the center’s star level. It is the center operator’s responsibility to maintain the same point level under each component at all times. If changes occur that may affect your rated license, please notify your licensing consultant to inform her of the changes and discuss a plan of action to maintain the center’s star rating. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a) A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. Consultation: We discussed staff member’s WORKS letters during the visit. 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 licensing 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 as needed. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. Please continue to visit DCDEE’s website to get the latest COVID-19 information for child care at https://ncchildcare.ncdhhs.gov/. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .2830 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/21/2025 Number Present: 39 Completed Date: 5/21/2025 Age: From 5 To 10 Total Minutes: 180 Time In: 02:00 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: ERS Announced/Unannounced: Announced The purpose of today’s announced visit was to review the results of your Environment Rating Scale assessment and to finalize your rated license assessment. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant and also signed by Sora Dowty, Program Coordinator, during the visit. A signed copy of the visit summary was electronically emailed to Delaney Burke, Senior Operations Director. Lily Elder, Program Director, was on-site and available to answer and ask questions. The program operates with a three-star center license issued on 1/25/23. The special restrictions include daytime care, school-age only, meets enhanced space and reduced ratios. The playground area does not meet child care playground safety standards. Children are prohibited in the kitchen for any purpose. SACERS-U was conducted on 4/30/25. The Rated License Assessment visit was conducted on 5/5/25 and scored 5. Upon arrival, I announced my presence and the purpose of the visit. All items scoring four (4) points and under were discussed with the Environment Rating Scale (ERS) Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today. There was a total of twenty (27) children present, and thirty-three (33) children enrolled. One (1) existing staff file was reviewed for updated CPR and First Aid certificate. The Child Care Center Item Number Listing (DCDEE-0357) was used as a basic monitoring tool to assess compliance with applicable child care requirements pertinent to this facility. The following items were reviewed for SACERS-U assessment: Item 2- 5.1 & 5.2: Outdoor play must be provided to the children on a daily basis whether permitted. Outdoor requirements do not apply to the program. Per interview with Ms. Elder, there may have been a language barrier on how a staff member responded to the interview question. Ms. Elder stated that children in this program goes outside on a daily basis with reasonable adjustments based on weather and children’s needs. Item 14 – 3.1: The loose surfacing is not required for this program per licensing restrictions. Item 17- 3.5: tables must be cleaned with soapy water and bleach solutions appropriately prior to each meal. This may be a violation of 15A NCAC 18A.2822(a)(1-4). Tables were cleaned with soapy water and sanitizing solutions prior to children’s arrival during the visit. Item 18 – 5.1: Handwashing shall be conducted appropriately. Per 15A NCAC 18A.2803(c), Children shall wash their hands upon arrival at the center, after each visit to the toilet, before eating, and before and after water play, after outside play, and/or after handling animals or animal cages. Additionally, 15A NCAC 18A.2803(a) states that Staff shall wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Upon arrival, children put their backpacks in the basket and gathered on a specific section in the cafeteria. Most children read books and talked with friends while all the children arrived. One (1) child moved to the tables where the materials were set up and played with toy animals, and one (1) child sat in the quiet area (individual tent) for appropriately five (5) minutes. When all the children arrived, the group lined up, went to the gym and used the bathroom to wash their hands. The materials used prior to handwashing were not moved. Item 18 – 5.2: lavatories must be kept clean per 15A NCAC 18A.2818(a). Per interview with staff members, the bathrooms are cleaned daily by the school custodians. I observed some paper towels on the floor. However, it was not possible for the group leaders to go into the bathroom and clean the bathroom as well as supervising the children. Item 20 – 5.1 and 5.2: Music and rhythm activities must be available weekly per 10A NCAC 09 .0510(c)(1). However, the types of musical instruments and the props are not a part of licensing requirements. Per Ms. Elder, music and rhythm materials are maintained in the cabinet and available for use weekly. No musical instruments were accessible to the children during the visit. Item 21 – 5.3: This is not a licensing requirement. Item 22 – 5.2: This is not a licensing requirement. However, extending child’s play nurture children’s creativity and approaches learning. Item 23- 5.1: This is not a licensing requirement. Item 23 – 5.2: This is not a licensing requirement. However, reading to children are important part of language and literacy development. The staff members should provide reading opportunities frequently. Per Ms. Elder, the program uses Kidz-Lit curriculum. This is the literacy curriculum where children and staff read a book followed by related activities and discussions over several days. Though the reading activity is not offered daily, the activities for Kidz-Lit is based on the reading and enriches overall literacy activities. Item 23 -5.3: Daily activity shall be designed to stimulate language development and communication per .0508(b)(1-5). Children in group #2 engages in group discussion upon arrival while children in group #1 uses the bathroom. Additionally, various games and books are accessible to the children daily. Apple to Apple Junior, Spapzi, Spot it! games were accessible to the children during today’s visit. Item 24 – 5.2: Daily activity shall be designed to stimulate cognitive development per .0508(b)(1-5). During the visit, I observed math related play materials, such as Plus Plus Blocks, Buildzi puzzles, chess, uno dominos and magnetic tiles. Item 25 – 3.2: Science and nature activities must be available weekly per .0510(c)(2). I observed one (1) children brought Red Clover plants and talked about it with other children. There were Science viewer kit and 3D insect specimens were accessible to the children during the visit. Item 29 – 5.4: even though this is not a licensing requirements, open-ended questions are effective ways to promote critical thinking. Item 36 – 5.3: for the program offers five (5) hours or less per day, a minimum of thirty (30) minutes of outdoor time is required weather permitted, per .0508(c). Both children in group #1 and group #2 played on the playground during today’s visit. The following violations of child care requirements observed: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. The program's safe arrival/departure policy was posted in the cafeteria. Per policy, the parents are expected to enter the facility and sign out of the children. However, the current procedure for this program is to sign in/out of the children using Daxko apps. .1003(b) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A container of Vomit Control was located on the table in the cafeteria. .2820(b) Technical assistance for correction plan: 801: Safe pick-up procedures must be established and followed, per .1003(b). The procedures of arrival/departure posted on site did not match the current practice using Daxko app. This item was corrected during the visit. Refer to 10A NCAC 09 .1003(b). 840: Potentially hazardous item A container of Vomit Control was found on the table on the corner of cafeteria being accessible to the children. The container was removed during the visit. Refer to 15A NCAC 18A.2820(b). Achieving Compliance: Due to all violations being corrected during the visit, you are not required to submit a letter of compliance. Please continue to maintain the compliance. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Rated License Assessment: Compliance History: The program must maintain a 75% or higher compliance history score to be eligible for a 2-5 star rated license. The compliance history for the facility prior to the visit today was ninety-five (95) percent. Staff Education: It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submitted an official transcript (if applicable) and applied 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. Staff education and experience is under review. Program Standards: Program Standards: I reviewed the requirements for .2806. Based on the schedule, lesson plans and room set up in space #4, creative activities, cultural activities, games/manipulatives, homework time, reading activities, social skills/life skills/problem solving activities and structured/unstructured physical activities are offered to children daily. The program follows enhanced space and reduced ratios, and the SACERS-U score was 5.03. Based on the information above, the program points for the program is expected to be seven (7) points. Quality Point: A quality point is met by meeting requirements for the staff benefits package(vacation, sick time, retirement, and health insurance) and infrastructure of parent involvement (quarterly newsletter and periodic conferences for all children). Quality Point = 1 point. Total points will be determined after education is evaluated. After final review, points under each component may change. The centers rated license assessment is due once every three years based on the date of the completed Environment Rating Scale scores, if applicable. During the three-year reassessment, the center’s program standards, staff education and a quality point option are determined to award the center’s star level. It is the center operator’s responsibility to maintain the same point level under each component at all times. If changes occur that may affect your rated license, please notify your licensing consultant to inform her of the changes and discuss a plan of action to maintain the center’s star rating. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a) A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. Consultation: We discussed staff member’s WORKS letters during the visit. 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 licensing 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 as needed. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. Please continue to visit DCDEE’s website to get the latest COVID-19 information for child care at https://ncchildcare.ncdhhs.gov/. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

G.S. 110-90 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/21/2025 Number Present: 39 Completed Date: 5/21/2025 Age: From 5 To 10 Total Minutes: 180 Time In: 02:00 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: ERS Announced/Unannounced: Announced The purpose of today’s announced visit was to review the results of your Environment Rating Scale assessment and to finalize your rated license assessment. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaoru Eddins, Child Care Consultant and also signed by Sora Dowty, Program Coordinator, during the visit. A signed copy of the visit summary was electronically emailed to Delaney Burke, Senior Operations Director. Lily Elder, Program Director, was on-site and available to answer and ask questions. The program operates with a three-star center license issued on 1/25/23. The special restrictions include daytime care, school-age only, meets enhanced space and reduced ratios. The playground area does not meet child care playground safety standards. Children are prohibited in the kitchen for any purpose. SACERS-U was conducted on 4/30/25. The Rated License Assessment visit was conducted on 5/5/25 and scored 5. Upon arrival, I announced my presence and the purpose of the visit. All items scoring four (4) points and under were discussed with the Environment Rating Scale (ERS) Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today. There was a total of twenty (27) children present, and thirty-three (33) children enrolled. One (1) existing staff file was reviewed for updated CPR and First Aid certificate. The Child Care Center Item Number Listing (DCDEE-0357) was used as a basic monitoring tool to assess compliance with applicable child care requirements pertinent to this facility. The following items were reviewed for SACERS-U assessment: Item 2- 5.1 & 5.2: Outdoor play must be provided to the children on a daily basis whether permitted. Outdoor requirements do not apply to the program. Per interview with Ms. Elder, there may have been a language barrier on how a staff member responded to the interview question. Ms. Elder stated that children in this program goes outside on a daily basis with reasonable adjustments based on weather and children’s needs. Item 14 – 3.1: The loose surfacing is not required for this program per licensing restrictions. Item 17- 3.5: tables must be cleaned with soapy water and bleach solutions appropriately prior to each meal. This may be a violation of 15A NCAC 18A.2822(a)(1-4). Tables were cleaned with soapy water and sanitizing solutions prior to children’s arrival during the visit. Item 18 – 5.1: Handwashing shall be conducted appropriately. Per 15A NCAC 18A.2803(c), Children shall wash their hands upon arrival at the center, after each visit to the toilet, before eating, and before and after water play, after outside play, and/or after handling animals or animal cages. Additionally, 15A NCAC 18A.2803(a) states that Staff shall wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Upon arrival, children put their backpacks in the basket and gathered on a specific section in the cafeteria. Most children read books and talked with friends while all the children arrived. One (1) child moved to the tables where the materials were set up and played with toy animals, and one (1) child sat in the quiet area (individual tent) for appropriately five (5) minutes. When all the children arrived, the group lined up, went to the gym and used the bathroom to wash their hands. The materials used prior to handwashing were not moved. Item 18 – 5.2: lavatories must be kept clean per 15A NCAC 18A.2818(a). Per interview with staff members, the bathrooms are cleaned daily by the school custodians. I observed some paper towels on the floor. However, it was not possible for the group leaders to go into the bathroom and clean the bathroom as well as supervising the children. Item 20 – 5.1 and 5.2: Music and rhythm activities must be available weekly per 10A NCAC 09 .0510(c)(1). However, the types of musical instruments and the props are not a part of licensing requirements. Per Ms. Elder, music and rhythm materials are maintained in the cabinet and available for use weekly. No musical instruments were accessible to the children during the visit. Item 21 – 5.3: This is not a licensing requirement. Item 22 – 5.2: This is not a licensing requirement. However, extending child’s play nurture children’s creativity and approaches learning. Item 23- 5.1: This is not a licensing requirement. Item 23 – 5.2: This is not a licensing requirement. However, reading to children are important part of language and literacy development. The staff members should provide reading opportunities frequently. Per Ms. Elder, the program uses Kidz-Lit curriculum. This is the literacy curriculum where children and staff read a book followed by related activities and discussions over several days. Though the reading activity is not offered daily, the activities for Kidz-Lit is based on the reading and enriches overall literacy activities. Item 23 -5.3: Daily activity shall be designed to stimulate language development and communication per .0508(b)(1-5). Children in group #2 engages in group discussion upon arrival while children in group #1 uses the bathroom. Additionally, various games and books are accessible to the children daily. Apple to Apple Junior, Spapzi, Spot it! games were accessible to the children during today’s visit. Item 24 – 5.2: Daily activity shall be designed to stimulate cognitive development per .0508(b)(1-5). During the visit, I observed math related play materials, such as Plus Plus Blocks, Buildzi puzzles, chess, uno dominos and magnetic tiles. Item 25 – 3.2: Science and nature activities must be available weekly per .0510(c)(2). I observed one (1) children brought Red Clover plants and talked about it with other children. There were Science viewer kit and 3D insect specimens were accessible to the children during the visit. Item 29 – 5.4: even though this is not a licensing requirements, open-ended questions are effective ways to promote critical thinking. Item 36 – 5.3: for the program offers five (5) hours or less per day, a minimum of thirty (30) minutes of outdoor time is required weather permitted, per .0508(c). Both children in group #1 and group #2 played on the playground during today’s visit. The following violations of child care requirements observed: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. The program's safe arrival/departure policy was posted in the cafeteria. Per policy, the parents are expected to enter the facility and sign out of the children. However, the current procedure for this program is to sign in/out of the children using Daxko apps. .1003(b) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A container of Vomit Control was located on the table in the cafeteria. .2820(b) Technical assistance for correction plan: 801: Safe pick-up procedures must be established and followed, per .1003(b). The procedures of arrival/departure posted on site did not match the current practice using Daxko app. This item was corrected during the visit. Refer to 10A NCAC 09 .1003(b). 840: Potentially hazardous item A container of Vomit Control was found on the table on the corner of cafeteria being accessible to the children. The container was removed during the visit. Refer to 15A NCAC 18A.2820(b). Achieving Compliance: Due to all violations being corrected during the visit, you are not required to submit a letter of compliance. Please continue to maintain the compliance. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Rated License Assessment: Compliance History: The program must maintain a 75% or higher compliance history score to be eligible for a 2-5 star rated license. The compliance history for the facility prior to the visit today was ninety-five (95) percent. Staff Education: It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submitted an official transcript (if applicable) and applied 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. Staff education and experience is under review. Program Standards: Program Standards: I reviewed the requirements for .2806. Based on the schedule, lesson plans and room set up in space #4, creative activities, cultural activities, games/manipulatives, homework time, reading activities, social skills/life skills/problem solving activities and structured/unstructured physical activities are offered to children daily. The program follows enhanced space and reduced ratios, and the SACERS-U score was 5.03. Based on the information above, the program points for the program is expected to be seven (7) points. Quality Point: A quality point is met by meeting requirements for the staff benefits package(vacation, sick time, retirement, and health insurance) and infrastructure of parent involvement (quarterly newsletter and periodic conferences for all children). Quality Point = 1 point. Total points will be determined after education is evaluated. After final review, points under each component may change. The centers rated license assessment is due once every three years based on the date of the completed Environment Rating Scale scores, if applicable. During the three-year reassessment, the center’s program standards, staff education and a quality point option are determined to award the center’s star level. It is the center operator’s responsibility to maintain the same point level under each component at all times. If changes occur that may affect your rated license, please notify your licensing consultant to inform her of the changes and discuss a plan of action to maintain the center’s star rating. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a) A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. Consultation: We discussed staff member’s WORKS letters during the visit. 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 licensing 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 as needed. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. Please continue to visit DCDEE’s website to get the latest COVID-19 information for child care at https://ncchildcare.ncdhhs.gov/. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaoru.eddins@dhhs.nc.gov or 828.556.9013, 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

10A NCAC 09 .0701 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 3/27/2025 Number Present: 43 Completed Date: 3/27/2025 Age: From 5 To 10 Total Minutes: 202 Time In: 02:08 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Rated License Assessment Announced/Unannounced: Announced The purpose of today’s visit was to monitor compliance during a Rated License Assessment visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins, Child Care Consultant and also signed by Joshua Willoughby, Program Coordinator, during the visit. A singed copy of the visit summary was to Delaney Burke, Senior Operations Director. Mr. Willoughby was available to ask and answer questions during the visit. The following items were monitored. Supervision Staff Child Ratios CPR First Aid Special Training Storage of Hazardous Substances Adequate/Approved Space Program Records License Posted Permit Restrictions New Staff files The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred (100) percent as of today prior to this visit. Permit type – Three-star center license issued on 5/12/21. Special Services/Restrictions – daytime care, school-age only, meets enhanced space, meets reduced ratios, playground does not meet child care safety standards. Children are prohibited in the kitchen for any purpose. Upon arrival, I announced my presence and the purpose of the visit. Upon arrival, all the children gathered in the gym. The children put their backpacks and personal belongings in the basket. The children were separated in three groups and supervised by the group leaders. Two (2) children in group #1 asked to go to the bathroom during the arrival process. The group leader stood on the corner where he/she could see the gym and the bathroom entrance. After checking in, the group transitioned to use the bathroom. Some children got snacks from their backpacks and taken the food with them. The children in group #1 and #3 put their snacks on the cafeteria tables before using the bathroom, The children in group #2 put their snacks on the floor while using the bathroom. After using the bathroom and washing their hands, all the children transitioned to the cafeteria. Staff members were able to see or hear children during the transition. In the cafeteria, snacks were served to all children whether they had snacks from home or not. Today, plain 1% milk, BBQ Jack links, sunflower kernels, bean and veggie crackers, apple sauce and veggie juice blend were served. All items were accurately listed on the menu. After the snack, the groups started rotating between the gym and the trailer. The children played with playdough, musical instruments, beads and string, manipulative and dramatic play materials. Two(2) emergency medications were maintained. Both Epi-pens were stored appropriately. The medication authorizations were both dated on 7/29/24, but both action plans were valid. The playground was briefly monitored due to concerns about air quality. The children did not play on the playground due to air quality concerns as well. No apparent safety hazards were observed. Lily Elder, Program Director, met with me via TEAMS and reviewed the files prior to this visit. Three (3) existing staff members’ files were monitored partially for criminal background letters, BSAC and First Aid/CPR certificates. All existing staff members have current letters and certificates. One (1) new staff member’s file was reviewed in full. Ms. Burke’s correct expiration date for her criminal background letter on the Staff and Training Worksheet is 1/25/27. The ABCMS system was reviewed prior to this visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 following violations were cited during today's visit. Violation Number Comment Rule 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. The Staff/Child ratio information sheet was not posted in the gym. .0713(a)(10), (c) & (f)(3); .2818(e) 609 Staff did not wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and after handling soiled items. All three (3) staff members handed bags of snacks to the children. The staff members did not wash their hands prior to handling the food. 15A NCAC 18A .2803(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. .2820(b) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. The emergency information form for a staff member hired on 11/22/24 was created and signed on 12/4/24. .0701(a) Technical assistance was provided as follows: 319: Staff/Child Ratio information The information on Staff/Child Ratio must be posted in each classroom. The information sheet was posted in the cafeteria and in the trailer. A copy must be posted in the gym. Please refer to 10A NCAC 09 .0713(a)(10). 609: Staff handwashing Staff must wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Is it possible to assign a child to pass the snack before he/she starts eating? If staff members are handling the food items, he/she needs to wash their hands prior to serving food. Refer to 15A NCAC 18A .2803(a). 840: Hazardous products A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. Due to a number of warnings, Vomit Control must be stored in a locked storage. Refer to 15A NCAC 18A.2820(b). 1035: Emergency information form Child care providers, including the director, uncompensated providers, substitute providers, and volunteers must have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. Make sure that all on-board staff members fill out the emergency information form prior to or on the first day of employment. Refer to 10A NCAC 09 .0701(a). Due to the effects of tropical storm Helene, additional time is permitted to achieve compliance for the following items: 1032: Medical Statement 1033: TB screening New staff members must provide Medical Statement and TB screening to the employer on or before the first day of employment. This is to ensure that the staff members have no risk of tuberculosis, and he/she/they are physically and mentally capable of taking care of children. The new staff member hired on 11/22/24 did not complete this process until 12/4/24 per Staff and Training Worksheet. Per conversation with the staff member hired on 11/22/24, making a doctor’s appointment was somewhat challenging in November. Refer to 10A NCAC 09 .0701(a). 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 • Statement of compliance • Signature of administrator I must receive your compliance statement by 4/10/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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 Assessment: Accessibility to the materials: All children in the group should have access to the required materials and activities. Minimal required times for daily access to various areas or materials are as follows: For programs operating 3 hours or more at least 30 minutes of access to materials is required. For programs that operate less than 3 hours, a minimum of 20 minutes of access is required. 14. Safety practice • Safety rules are taught to children. • staff members should conduct daily inspections to eliminate safety hazards on facilities, playgrounds and equipment. • emergency number should be posted near the phone. • emergency procedures should be posted. • First aid supplied should be well-stocked. • Hand sanitizers should be maintained out of reach of children. 17: Meal/snacks • staff members should sit with children during snacks when possible. • Children’s allergies or other food restrictions must be posted, and the appropriate substitutions must be served. 18. Personal Hygiene Handwashing: In certain situations, when a sink with running water is not accessible for the group to use, hand sanitizing products may be used in lieu of handwashing. For example, hand sanitizer may be used while staff is supervising children outdoors, if hands are washed upon returning indoors. The following requirements must be met: the waterless wash or wipe must be used according to manufacturer guidelines (i.e.., labeled as safe for use by children, used only with adult supervision, allowed to dry properly), and the waterless wash must be stored out of reach of children. Please note that this substitution is only acceptable in certain circumstances and that the requirements for adequate handwashing still apply for routine care activities and general classroom use. Proper hand washing for adults and children: Includes use of running water and soap for approximately 15-20 seconds, followed by drying with an individual paper towel or air dryer. • Hand hygiene is practiced upon arrival, before/after eating, after messy activities and outdoor play, after toileting, etc. • Staff shall check bathrooms for cleanliness and supplies periodically. • Teach children not to share personal items, such as combs, food and drink. • Staff member also washes hands upon arrival, before/after handling food, after outdoor play, etc. 20. Music and Movement • Music and movement activities shall be accessible for free choice, including listening to music, dancing and playing with musical instruments. • Various types of musical experience are accessible. The examples are classical, pop music, different languages, musical instruments and different cultures. 22. Dramatic play/theatre • Examples of materials include dress-up clothes, costumes, props, and puppets. • Variety of dramatic play materials for both boys and girls that support many roles and situations shall be available. Examples of roles/situation include work, adventure, fantasy, theatrical productions. • Staff shall extend dramatic play by offering suggestions, finding appropriate space and assisting development of dramatic roles. 23. Language/reading activities • Examples of materials include print materials, such as books, dictionaries, encyclopedia, audio materials and games. • Many appropriate books and language games are accessible daily. • There shall be no graphic description of violence or prejudice in books. • Age-appropriate stories are read or told at least weekly. • Children are encouraged to use reading/writing in practical situations, such as write letters to friends, reading instructions for games, retrieve information online, etc.) 24. Math/reasoning activities • Examples of materials include puzzles, number games, dominoes, Veritec, board game, such as Chutes and Ladders. • For grade 1 and up, chess, checkers, Veritec, backgammon, dominoes, this category. • Variety of age-appropriate math/reasoning game and/or activities are accessible for free choice daily. At least 3-5 different games/activities shall be accessible. • Staff encourage children to practice math/reasoning skills in daily activities. Staff shall link math and numbers to practical life events in the children’s daily schedule. Use opportunities, such as meal time, counting number of children, transition times, use timer for taking turns, keeping scores in ball games, taking attendance by children, taking about times using clock, etc. 25. Science/nature activities • Equipment examples include aquarium, terrarium, measuring tools, magnifying glasses, magnets, scales, microscope. • Materials examples include natural objects, living things, realistic books, posters, pictures, and science games. • Special activities for extended opportunity to observe nature is offered at least twice a year. Examples are watching caterpillars turn into butterflies, planting and caring for a garden. 26 Cultural Awareness • At least four easily visible examples of different types of diversity must be present, other than gender. Examples are multi-cultural books, pictures of various countries and races, books in more than one language bilingual community, dolls or block accessory people of different races, ages. • In addition to cultural diversity, no inappropriate materials, such as pictures and books depicting males and females in non-traditional roles are visible. • Staff must display a non-biased approach to activities. For example, girls are encouraged to participate in carpentry, and boys are encouraged to participate in cooking. 28 Staff-Child interactions • Staff respond to children in a warm, supportive manner. Staff show respect for children. • For 7 pt level, staff shall support children and take the lead in selecting and initiating activities. 29 staff-child communication • Staff communicates with children frequently. • Children ask why, how and what if questions. • For 7 pts level, staff shall make effort to talk with each child and expand on ideas presented by children. 30 Staff supervision of children • Supervision shall be provided to all children, and the adjustment shall be made for younger and more challenging children to supervise them more closely. • Staff shall provide help and encouragement to children as needed. • Staff shall show appreciation of children’s effort and accomplishments. 36 Schedule • Flexibility is possible within the schedule • Both Staff-initiated and child-initiated activities shall be available. • Gross motor activities for all children outdoor shall be available daily (weather permitted). Gross motor activities: Daily outdoors for at least 30 minutes for programs operating 3+ hours unless severe weather prevents children from going outdoors. Provisions must also be made indoors for the same amount of time on those days when children cannot play outdoors. Overall access to stationary gross motor equipment throughout the week; equipment must offer at least 5 play possibilities (monkey bars, slide, tunnel, balance beam, playing basketball, etc.). Children must have access to some stationary equipment daily, weather permitting, and must have access to stationary gross motor equipment that provides a variety of play opportunities over the course of the week. Stationary gross motor equipment must be provided that stimulates at least 5 different skills overall for the observed group, and all children in the group must have some appropriate equipment. To score this indicator, look at children’s overall access to stationary gross motor equipment throughout the week. The portable equipment must be accessible daily and stimulate 5 different skills. On days when children do not go outside, these materials must be provided indoors. Portable gross motor equipment is provided that stimulates at least 5 different skills overall for the observed group, with some choice in materials. Consultation: Health Questionnaire The Health questionnaire is required for the second year of employment and must be updated annually thereafter. 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 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013 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 .0713 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 3/27/2025 Number Present: 43 Completed Date: 3/27/2025 Age: From 5 To 10 Total Minutes: 202 Time In: 02:08 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Rated License Assessment Announced/Unannounced: Announced The purpose of today’s visit was to monitor compliance during a Rated License Assessment visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins, Child Care Consultant and also signed by Joshua Willoughby, Program Coordinator, during the visit. A singed copy of the visit summary was to Delaney Burke, Senior Operations Director. Mr. Willoughby was available to ask and answer questions during the visit. The following items were monitored. Supervision Staff Child Ratios CPR First Aid Special Training Storage of Hazardous Substances Adequate/Approved Space Program Records License Posted Permit Restrictions New Staff files The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred (100) percent as of today prior to this visit. Permit type – Three-star center license issued on 5/12/21. Special Services/Restrictions – daytime care, school-age only, meets enhanced space, meets reduced ratios, playground does not meet child care safety standards. Children are prohibited in the kitchen for any purpose. Upon arrival, I announced my presence and the purpose of the visit. Upon arrival, all the children gathered in the gym. The children put their backpacks and personal belongings in the basket. The children were separated in three groups and supervised by the group leaders. Two (2) children in group #1 asked to go to the bathroom during the arrival process. The group leader stood on the corner where he/she could see the gym and the bathroom entrance. After checking in, the group transitioned to use the bathroom. Some children got snacks from their backpacks and taken the food with them. The children in group #1 and #3 put their snacks on the cafeteria tables before using the bathroom, The children in group #2 put their snacks on the floor while using the bathroom. After using the bathroom and washing their hands, all the children transitioned to the cafeteria. Staff members were able to see or hear children during the transition. In the cafeteria, snacks were served to all children whether they had snacks from home or not. Today, plain 1% milk, BBQ Jack links, sunflower kernels, bean and veggie crackers, apple sauce and veggie juice blend were served. All items were accurately listed on the menu. After the snack, the groups started rotating between the gym and the trailer. The children played with playdough, musical instruments, beads and string, manipulative and dramatic play materials. Two(2) emergency medications were maintained. Both Epi-pens were stored appropriately. The medication authorizations were both dated on 7/29/24, but both action plans were valid. The playground was briefly monitored due to concerns about air quality. The children did not play on the playground due to air quality concerns as well. No apparent safety hazards were observed. Lily Elder, Program Director, met with me via TEAMS and reviewed the files prior to this visit. Three (3) existing staff members’ files were monitored partially for criminal background letters, BSAC and First Aid/CPR certificates. All existing staff members have current letters and certificates. One (1) new staff member’s file was reviewed in full. Ms. Burke’s correct expiration date for her criminal background letter on the Staff and Training Worksheet is 1/25/27. The ABCMS system was reviewed prior to this visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 following violations were cited during today's visit. Violation Number Comment Rule 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. The Staff/Child ratio information sheet was not posted in the gym. .0713(a)(10), (c) & (f)(3); .2818(e) 609 Staff did not wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and after handling soiled items. All three (3) staff members handed bags of snacks to the children. The staff members did not wash their hands prior to handling the food. 15A NCAC 18A .2803(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. .2820(b) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. The emergency information form for a staff member hired on 11/22/24 was created and signed on 12/4/24. .0701(a) Technical assistance was provided as follows: 319: Staff/Child Ratio information The information on Staff/Child Ratio must be posted in each classroom. The information sheet was posted in the cafeteria and in the trailer. A copy must be posted in the gym. Please refer to 10A NCAC 09 .0713(a)(10). 609: Staff handwashing Staff must wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Is it possible to assign a child to pass the snack before he/she starts eating? If staff members are handling the food items, he/she needs to wash their hands prior to serving food. Refer to 15A NCAC 18A .2803(a). 840: Hazardous products A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. Due to a number of warnings, Vomit Control must be stored in a locked storage. Refer to 15A NCAC 18A.2820(b). 1035: Emergency information form Child care providers, including the director, uncompensated providers, substitute providers, and volunteers must have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. Make sure that all on-board staff members fill out the emergency information form prior to or on the first day of employment. Refer to 10A NCAC 09 .0701(a). Due to the effects of tropical storm Helene, additional time is permitted to achieve compliance for the following items: 1032: Medical Statement 1033: TB screening New staff members must provide Medical Statement and TB screening to the employer on or before the first day of employment. This is to ensure that the staff members have no risk of tuberculosis, and he/she/they are physically and mentally capable of taking care of children. The new staff member hired on 11/22/24 did not complete this process until 12/4/24 per Staff and Training Worksheet. Per conversation with the staff member hired on 11/22/24, making a doctor’s appointment was somewhat challenging in November. Refer to 10A NCAC 09 .0701(a). 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 • Statement of compliance • Signature of administrator I must receive your compliance statement by 4/10/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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 Assessment: Accessibility to the materials: All children in the group should have access to the required materials and activities. Minimal required times for daily access to various areas or materials are as follows: For programs operating 3 hours or more at least 30 minutes of access to materials is required. For programs that operate less than 3 hours, a minimum of 20 minutes of access is required. 14. Safety practice • Safety rules are taught to children. • staff members should conduct daily inspections to eliminate safety hazards on facilities, playgrounds and equipment. • emergency number should be posted near the phone. • emergency procedures should be posted. • First aid supplied should be well-stocked. • Hand sanitizers should be maintained out of reach of children. 17: Meal/snacks • staff members should sit with children during snacks when possible. • Children’s allergies or other food restrictions must be posted, and the appropriate substitutions must be served. 18. Personal Hygiene Handwashing: In certain situations, when a sink with running water is not accessible for the group to use, hand sanitizing products may be used in lieu of handwashing. For example, hand sanitizer may be used while staff is supervising children outdoors, if hands are washed upon returning indoors. The following requirements must be met: the waterless wash or wipe must be used according to manufacturer guidelines (i.e.., labeled as safe for use by children, used only with adult supervision, allowed to dry properly), and the waterless wash must be stored out of reach of children. Please note that this substitution is only acceptable in certain circumstances and that the requirements for adequate handwashing still apply for routine care activities and general classroom use. Proper hand washing for adults and children: Includes use of running water and soap for approximately 15-20 seconds, followed by drying with an individual paper towel or air dryer. • Hand hygiene is practiced upon arrival, before/after eating, after messy activities and outdoor play, after toileting, etc. • Staff shall check bathrooms for cleanliness and supplies periodically. • Teach children not to share personal items, such as combs, food and drink. • Staff member also washes hands upon arrival, before/after handling food, after outdoor play, etc. 20. Music and Movement • Music and movement activities shall be accessible for free choice, including listening to music, dancing and playing with musical instruments. • Various types of musical experience are accessible. The examples are classical, pop music, different languages, musical instruments and different cultures. 22. Dramatic play/theatre • Examples of materials include dress-up clothes, costumes, props, and puppets. • Variety of dramatic play materials for both boys and girls that support many roles and situations shall be available. Examples of roles/situation include work, adventure, fantasy, theatrical productions. • Staff shall extend dramatic play by offering suggestions, finding appropriate space and assisting development of dramatic roles. 23. Language/reading activities • Examples of materials include print materials, such as books, dictionaries, encyclopedia, audio materials and games. • Many appropriate books and language games are accessible daily. • There shall be no graphic description of violence or prejudice in books. • Age-appropriate stories are read or told at least weekly. • Children are encouraged to use reading/writing in practical situations, such as write letters to friends, reading instructions for games, retrieve information online, etc.) 24. Math/reasoning activities • Examples of materials include puzzles, number games, dominoes, Veritec, board game, such as Chutes and Ladders. • For grade 1 and up, chess, checkers, Veritec, backgammon, dominoes, this category. • Variety of age-appropriate math/reasoning game and/or activities are accessible for free choice daily. At least 3-5 different games/activities shall be accessible. • Staff encourage children to practice math/reasoning skills in daily activities. Staff shall link math and numbers to practical life events in the children’s daily schedule. Use opportunities, such as meal time, counting number of children, transition times, use timer for taking turns, keeping scores in ball games, taking attendance by children, taking about times using clock, etc. 25. Science/nature activities • Equipment examples include aquarium, terrarium, measuring tools, magnifying glasses, magnets, scales, microscope. • Materials examples include natural objects, living things, realistic books, posters, pictures, and science games. • Special activities for extended opportunity to observe nature is offered at least twice a year. Examples are watching caterpillars turn into butterflies, planting and caring for a garden. 26 Cultural Awareness • At least four easily visible examples of different types of diversity must be present, other than gender. Examples are multi-cultural books, pictures of various countries and races, books in more than one language bilingual community, dolls or block accessory people of different races, ages. • In addition to cultural diversity, no inappropriate materials, such as pictures and books depicting males and females in non-traditional roles are visible. • Staff must display a non-biased approach to activities. For example, girls are encouraged to participate in carpentry, and boys are encouraged to participate in cooking. 28 Staff-Child interactions • Staff respond to children in a warm, supportive manner. Staff show respect for children. • For 7 pt level, staff shall support children and take the lead in selecting and initiating activities. 29 staff-child communication • Staff communicates with children frequently. • Children ask why, how and what if questions. • For 7 pts level, staff shall make effort to talk with each child and expand on ideas presented by children. 30 Staff supervision of children • Supervision shall be provided to all children, and the adjustment shall be made for younger and more challenging children to supervise them more closely. • Staff shall provide help and encouragement to children as needed. • Staff shall show appreciation of children’s effort and accomplishments. 36 Schedule • Flexibility is possible within the schedule • Both Staff-initiated and child-initiated activities shall be available. • Gross motor activities for all children outdoor shall be available daily (weather permitted). Gross motor activities: Daily outdoors for at least 30 minutes for programs operating 3+ hours unless severe weather prevents children from going outdoors. Provisions must also be made indoors for the same amount of time on those days when children cannot play outdoors. Overall access to stationary gross motor equipment throughout the week; equipment must offer at least 5 play possibilities (monkey bars, slide, tunnel, balance beam, playing basketball, etc.). Children must have access to some stationary equipment daily, weather permitting, and must have access to stationary gross motor equipment that provides a variety of play opportunities over the course of the week. Stationary gross motor equipment must be provided that stimulates at least 5 different skills overall for the observed group, and all children in the group must have some appropriate equipment. To score this indicator, look at children’s overall access to stationary gross motor equipment throughout the week. The portable equipment must be accessible daily and stimulate 5 different skills. On days when children do not go outside, these materials must be provided indoors. Portable gross motor equipment is provided that stimulates at least 5 different skills overall for the observed group, with some choice in materials. Consultation: Health Questionnaire The Health questionnaire is required for the second year of employment and must be updated annually thereafter. 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 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013 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

10A NCAC 09 .2830 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 3/27/2025 Number Present: 43 Completed Date: 3/27/2025 Age: From 5 To 10 Total Minutes: 202 Time In: 02:08 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Rated License Assessment Announced/Unannounced: Announced The purpose of today’s visit was to monitor compliance during a Rated License Assessment visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins, Child Care Consultant and also signed by Joshua Willoughby, Program Coordinator, during the visit. A singed copy of the visit summary was to Delaney Burke, Senior Operations Director. Mr. Willoughby was available to ask and answer questions during the visit. The following items were monitored. Supervision Staff Child Ratios CPR First Aid Special Training Storage of Hazardous Substances Adequate/Approved Space Program Records License Posted Permit Restrictions New Staff files The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred (100) percent as of today prior to this visit. Permit type – Three-star center license issued on 5/12/21. Special Services/Restrictions – daytime care, school-age only, meets enhanced space, meets reduced ratios, playground does not meet child care safety standards. Children are prohibited in the kitchen for any purpose. Upon arrival, I announced my presence and the purpose of the visit. Upon arrival, all the children gathered in the gym. The children put their backpacks and personal belongings in the basket. The children were separated in three groups and supervised by the group leaders. Two (2) children in group #1 asked to go to the bathroom during the arrival process. The group leader stood on the corner where he/she could see the gym and the bathroom entrance. After checking in, the group transitioned to use the bathroom. Some children got snacks from their backpacks and taken the food with them. The children in group #1 and #3 put their snacks on the cafeteria tables before using the bathroom, The children in group #2 put their snacks on the floor while using the bathroom. After using the bathroom and washing their hands, all the children transitioned to the cafeteria. Staff members were able to see or hear children during the transition. In the cafeteria, snacks were served to all children whether they had snacks from home or not. Today, plain 1% milk, BBQ Jack links, sunflower kernels, bean and veggie crackers, apple sauce and veggie juice blend were served. All items were accurately listed on the menu. After the snack, the groups started rotating between the gym and the trailer. The children played with playdough, musical instruments, beads and string, manipulative and dramatic play materials. Two(2) emergency medications were maintained. Both Epi-pens were stored appropriately. The medication authorizations were both dated on 7/29/24, but both action plans were valid. The playground was briefly monitored due to concerns about air quality. The children did not play on the playground due to air quality concerns as well. No apparent safety hazards were observed. Lily Elder, Program Director, met with me via TEAMS and reviewed the files prior to this visit. Three (3) existing staff members’ files were monitored partially for criminal background letters, BSAC and First Aid/CPR certificates. All existing staff members have current letters and certificates. One (1) new staff member’s file was reviewed in full. Ms. Burke’s correct expiration date for her criminal background letter on the Staff and Training Worksheet is 1/25/27. The ABCMS system was reviewed prior to this visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 following violations were cited during today's visit. Violation Number Comment Rule 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. The Staff/Child ratio information sheet was not posted in the gym. .0713(a)(10), (c) & (f)(3); .2818(e) 609 Staff did not wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and after handling soiled items. All three (3) staff members handed bags of snacks to the children. The staff members did not wash their hands prior to handling the food. 15A NCAC 18A .2803(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. .2820(b) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. The emergency information form for a staff member hired on 11/22/24 was created and signed on 12/4/24. .0701(a) Technical assistance was provided as follows: 319: Staff/Child Ratio information The information on Staff/Child Ratio must be posted in each classroom. The information sheet was posted in the cafeteria and in the trailer. A copy must be posted in the gym. Please refer to 10A NCAC 09 .0713(a)(10). 609: Staff handwashing Staff must wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Is it possible to assign a child to pass the snack before he/she starts eating? If staff members are handling the food items, he/she needs to wash their hands prior to serving food. Refer to 15A NCAC 18A .2803(a). 840: Hazardous products A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. Due to a number of warnings, Vomit Control must be stored in a locked storage. Refer to 15A NCAC 18A.2820(b). 1035: Emergency information form Child care providers, including the director, uncompensated providers, substitute providers, and volunteers must have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. Make sure that all on-board staff members fill out the emergency information form prior to or on the first day of employment. Refer to 10A NCAC 09 .0701(a). Due to the effects of tropical storm Helene, additional time is permitted to achieve compliance for the following items: 1032: Medical Statement 1033: TB screening New staff members must provide Medical Statement and TB screening to the employer on or before the first day of employment. This is to ensure that the staff members have no risk of tuberculosis, and he/she/they are physically and mentally capable of taking care of children. The new staff member hired on 11/22/24 did not complete this process until 12/4/24 per Staff and Training Worksheet. Per conversation with the staff member hired on 11/22/24, making a doctor’s appointment was somewhat challenging in November. Refer to 10A NCAC 09 .0701(a). 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 • Statement of compliance • Signature of administrator I must receive your compliance statement by 4/10/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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 Assessment: Accessibility to the materials: All children in the group should have access to the required materials and activities. Minimal required times for daily access to various areas or materials are as follows: For programs operating 3 hours or more at least 30 minutes of access to materials is required. For programs that operate less than 3 hours, a minimum of 20 minutes of access is required. 14. Safety practice • Safety rules are taught to children. • staff members should conduct daily inspections to eliminate safety hazards on facilities, playgrounds and equipment. • emergency number should be posted near the phone. • emergency procedures should be posted. • First aid supplied should be well-stocked. • Hand sanitizers should be maintained out of reach of children. 17: Meal/snacks • staff members should sit with children during snacks when possible. • Children’s allergies or other food restrictions must be posted, and the appropriate substitutions must be served. 18. Personal Hygiene Handwashing: In certain situations, when a sink with running water is not accessible for the group to use, hand sanitizing products may be used in lieu of handwashing. For example, hand sanitizer may be used while staff is supervising children outdoors, if hands are washed upon returning indoors. The following requirements must be met: the waterless wash or wipe must be used according to manufacturer guidelines (i.e.., labeled as safe for use by children, used only with adult supervision, allowed to dry properly), and the waterless wash must be stored out of reach of children. Please note that this substitution is only acceptable in certain circumstances and that the requirements for adequate handwashing still apply for routine care activities and general classroom use. Proper hand washing for adults and children: Includes use of running water and soap for approximately 15-20 seconds, followed by drying with an individual paper towel or air dryer. • Hand hygiene is practiced upon arrival, before/after eating, after messy activities and outdoor play, after toileting, etc. • Staff shall check bathrooms for cleanliness and supplies periodically. • Teach children not to share personal items, such as combs, food and drink. • Staff member also washes hands upon arrival, before/after handling food, after outdoor play, etc. 20. Music and Movement • Music and movement activities shall be accessible for free choice, including listening to music, dancing and playing with musical instruments. • Various types of musical experience are accessible. The examples are classical, pop music, different languages, musical instruments and different cultures. 22. Dramatic play/theatre • Examples of materials include dress-up clothes, costumes, props, and puppets. • Variety of dramatic play materials for both boys and girls that support many roles and situations shall be available. Examples of roles/situation include work, adventure, fantasy, theatrical productions. • Staff shall extend dramatic play by offering suggestions, finding appropriate space and assisting development of dramatic roles. 23. Language/reading activities • Examples of materials include print materials, such as books, dictionaries, encyclopedia, audio materials and games. • Many appropriate books and language games are accessible daily. • There shall be no graphic description of violence or prejudice in books. • Age-appropriate stories are read or told at least weekly. • Children are encouraged to use reading/writing in practical situations, such as write letters to friends, reading instructions for games, retrieve information online, etc.) 24. Math/reasoning activities • Examples of materials include puzzles, number games, dominoes, Veritec, board game, such as Chutes and Ladders. • For grade 1 and up, chess, checkers, Veritec, backgammon, dominoes, this category. • Variety of age-appropriate math/reasoning game and/or activities are accessible for free choice daily. At least 3-5 different games/activities shall be accessible. • Staff encourage children to practice math/reasoning skills in daily activities. Staff shall link math and numbers to practical life events in the children’s daily schedule. Use opportunities, such as meal time, counting number of children, transition times, use timer for taking turns, keeping scores in ball games, taking attendance by children, taking about times using clock, etc. 25. Science/nature activities • Equipment examples include aquarium, terrarium, measuring tools, magnifying glasses, magnets, scales, microscope. • Materials examples include natural objects, living things, realistic books, posters, pictures, and science games. • Special activities for extended opportunity to observe nature is offered at least twice a year. Examples are watching caterpillars turn into butterflies, planting and caring for a garden. 26 Cultural Awareness • At least four easily visible examples of different types of diversity must be present, other than gender. Examples are multi-cultural books, pictures of various countries and races, books in more than one language bilingual community, dolls or block accessory people of different races, ages. • In addition to cultural diversity, no inappropriate materials, such as pictures and books depicting males and females in non-traditional roles are visible. • Staff must display a non-biased approach to activities. For example, girls are encouraged to participate in carpentry, and boys are encouraged to participate in cooking. 28 Staff-Child interactions • Staff respond to children in a warm, supportive manner. Staff show respect for children. • For 7 pt level, staff shall support children and take the lead in selecting and initiating activities. 29 staff-child communication • Staff communicates with children frequently. • Children ask why, how and what if questions. • For 7 pts level, staff shall make effort to talk with each child and expand on ideas presented by children. 30 Staff supervision of children • Supervision shall be provided to all children, and the adjustment shall be made for younger and more challenging children to supervise them more closely. • Staff shall provide help and encouragement to children as needed. • Staff shall show appreciation of children’s effort and accomplishments. 36 Schedule • Flexibility is possible within the schedule • Both Staff-initiated and child-initiated activities shall be available. • Gross motor activities for all children outdoor shall be available daily (weather permitted). Gross motor activities: Daily outdoors for at least 30 minutes for programs operating 3+ hours unless severe weather prevents children from going outdoors. Provisions must also be made indoors for the same amount of time on those days when children cannot play outdoors. Overall access to stationary gross motor equipment throughout the week; equipment must offer at least 5 play possibilities (monkey bars, slide, tunnel, balance beam, playing basketball, etc.). Children must have access to some stationary equipment daily, weather permitting, and must have access to stationary gross motor equipment that provides a variety of play opportunities over the course of the week. Stationary gross motor equipment must be provided that stimulates at least 5 different skills overall for the observed group, and all children in the group must have some appropriate equipment. To score this indicator, look at children’s overall access to stationary gross motor equipment throughout the week. The portable equipment must be accessible daily and stimulate 5 different skills. On days when children do not go outside, these materials must be provided indoors. Portable gross motor equipment is provided that stimulates at least 5 different skills overall for the observed group, with some choice in materials. Consultation: Health Questionnaire The Health questionnaire is required for the second year of employment and must be updated annually thereafter. 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 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013 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

NC GS 110-90 · Violation

Name of Operation: YMCA AVERY'S CREEK AFTERSCHOOL Facility ID: 11000668 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 3/27/2025 Number Present: 43 Completed Date: 3/27/2025 Age: From 5 To 10 Total Minutes: 202 Time In: 02:08 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Rated License Assessment Announced/Unannounced: Announced The purpose of today’s visit was to monitor compliance during a Rated License Assessment visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaoru Eddins, Child Care Consultant and also signed by Joshua Willoughby, Program Coordinator, during the visit. A singed copy of the visit summary was to Delaney Burke, Senior Operations Director. Mr. Willoughby was available to ask and answer questions during the visit. The following items were monitored. Supervision Staff Child Ratios CPR First Aid Special Training Storage of Hazardous Substances Adequate/Approved Space Program Records License Posted Permit Restrictions New Staff files The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred (100) percent as of today prior to this visit. Permit type – Three-star center license issued on 5/12/21. Special Services/Restrictions – daytime care, school-age only, meets enhanced space, meets reduced ratios, playground does not meet child care safety standards. Children are prohibited in the kitchen for any purpose. Upon arrival, I announced my presence and the purpose of the visit. Upon arrival, all the children gathered in the gym. The children put their backpacks and personal belongings in the basket. The children were separated in three groups and supervised by the group leaders. Two (2) children in group #1 asked to go to the bathroom during the arrival process. The group leader stood on the corner where he/she could see the gym and the bathroom entrance. After checking in, the group transitioned to use the bathroom. Some children got snacks from their backpacks and taken the food with them. The children in group #1 and #3 put their snacks on the cafeteria tables before using the bathroom, The children in group #2 put their snacks on the floor while using the bathroom. After using the bathroom and washing their hands, all the children transitioned to the cafeteria. Staff members were able to see or hear children during the transition. In the cafeteria, snacks were served to all children whether they had snacks from home or not. Today, plain 1% milk, BBQ Jack links, sunflower kernels, bean and veggie crackers, apple sauce and veggie juice blend were served. All items were accurately listed on the menu. After the snack, the groups started rotating between the gym and the trailer. The children played with playdough, musical instruments, beads and string, manipulative and dramatic play materials. Two(2) emergency medications were maintained. Both Epi-pens were stored appropriately. The medication authorizations were both dated on 7/29/24, but both action plans were valid. The playground was briefly monitored due to concerns about air quality. The children did not play on the playground due to air quality concerns as well. No apparent safety hazards were observed. Lily Elder, Program Director, met with me via TEAMS and reviewed the files prior to this visit. Three (3) existing staff members’ files were monitored partially for criminal background letters, BSAC and First Aid/CPR certificates. All existing staff members have current letters and certificates. One (1) new staff member’s file was reviewed in full. Ms. Burke’s correct expiration date for her criminal background letter on the Staff and Training Worksheet is 1/25/27. The ABCMS system was reviewed prior to this visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 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 following violations were cited during today's visit. Violation Number Comment Rule 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. The Staff/Child ratio information sheet was not posted in the gym. .0713(a)(10), (c) & (f)(3); .2818(e) 609 Staff did not wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and after handling soiled items. All three (3) staff members handed bags of snacks to the children. The staff members did not wash their hands prior to handling the food. 15A NCAC 18A .2803(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. .2820(b) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. The emergency information form for a staff member hired on 11/22/24 was created and signed on 12/4/24. .0701(a) Technical assistance was provided as follows: 319: Staff/Child Ratio information The information on Staff/Child Ratio must be posted in each classroom. The information sheet was posted in the cafeteria and in the trailer. A copy must be posted in the gym. Please refer to 10A NCAC 09 .0713(a)(10). 609: Staff handwashing Staff must wash their hands thoroughly before beginning work, before/after handling food, before bottle feeding or serving to other children, after toileting or handling body fluids, after diaper changing and/or after handling soiled items. Is it possible to assign a child to pass the snack before he/she starts eating? If staff members are handling the food items, he/she needs to wash their hands prior to serving food. Refer to 15A NCAC 18A .2803(a). 840: Hazardous products A bottle of Vomit Control was maintained on the corner table in cafeteria at approximately 26 ½ inch high. Vomit Control has several warnings, including keeping out of reach of children, causing serious eye irritation, and allergic skin reaction. Due to a number of warnings, Vomit Control must be stored in a locked storage. Refer to 15A NCAC 18A.2820(b). 1035: Emergency information form Child care providers, including the director, uncompensated providers, substitute providers, and volunteers must have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. Make sure that all on-board staff members fill out the emergency information form prior to or on the first day of employment. Refer to 10A NCAC 09 .0701(a). Due to the effects of tropical storm Helene, additional time is permitted to achieve compliance for the following items: 1032: Medical Statement 1033: TB screening New staff members must provide Medical Statement and TB screening to the employer on or before the first day of employment. This is to ensure that the staff members have no risk of tuberculosis, and he/she/they are physically and mentally capable of taking care of children. The new staff member hired on 11/22/24 did not complete this process until 12/4/24 per Staff and Training Worksheet. Per conversation with the staff member hired on 11/22/24, making a doctor’s appointment was somewhat challenging in November. Refer to 10A NCAC 09 .0701(a). 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 • Statement of compliance • Signature of administrator I must receive your compliance statement by 4/10/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaoru.eddins@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaoru Eddins PO Box 795 Pisgah Forest, NC 28768 Please call me at 828-556-9013, or email kaoru.eddins@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 Assessment: Accessibility to the materials: All children in the group should have access to the required materials and activities. Minimal required times for daily access to various areas or materials are as follows: For programs operating 3 hours or more at least 30 minutes of access to materials is required. For programs that operate less than 3 hours, a minimum of 20 minutes of access is required. 14. Safety practice • Safety rules are taught to children. • staff members should conduct daily inspections to eliminate safety hazards on facilities, playgrounds and equipment. • emergency number should be posted near the phone. • emergency procedures should be posted. • First aid supplied should be well-stocked. • Hand sanitizers should be maintained out of reach of children. 17: Meal/snacks • staff members should sit with children during snacks when possible. • Children’s allergies or other food restrictions must be posted, and the appropriate substitutions must be served. 18. Personal Hygiene Handwashing: In certain situations, when a sink with running water is not accessible for the group to use, hand sanitizing products may be used in lieu of handwashing. For example, hand sanitizer may be used while staff is supervising children outdoors, if hands are washed upon returning indoors. The following requirements must be met: the waterless wash or wipe must be used according to manufacturer guidelines (i.e.., labeled as safe for use by children, used only with adult supervision, allowed to dry properly), and the waterless wash must be stored out of reach of children. Please note that this substitution is only acceptable in certain circumstances and that the requirements for adequate handwashing still apply for routine care activities and general classroom use. Proper hand washing for adults and children: Includes use of running water and soap for approximately 15-20 seconds, followed by drying with an individual paper towel or air dryer. • Hand hygiene is practiced upon arrival, before/after eating, after messy activities and outdoor play, after toileting, etc. • Staff shall check bathrooms for cleanliness and supplies periodically. • Teach children not to share personal items, such as combs, food and drink. • Staff member also washes hands upon arrival, before/after handling food, after outdoor play, etc. 20. Music and Movement • Music and movement activities shall be accessible for free choice, including listening to music, dancing and playing with musical instruments. • Various types of musical experience are accessible. The examples are classical, pop music, different languages, musical instruments and different cultures. 22. Dramatic play/theatre • Examples of materials include dress-up clothes, costumes, props, and puppets. • Variety of dramatic play materials for both boys and girls that support many roles and situations shall be available. Examples of roles/situation include work, adventure, fantasy, theatrical productions. • Staff shall extend dramatic play by offering suggestions, finding appropriate space and assisting development of dramatic roles. 23. Language/reading activities • Examples of materials include print materials, such as books, dictionaries, encyclopedia, audio materials and games. • Many appropriate books and language games are accessible daily. • There shall be no graphic description of violence or prejudice in books. • Age-appropriate stories are read or told at least weekly. • Children are encouraged to use reading/writing in practical situations, such as write letters to friends, reading instructions for games, retrieve information online, etc.) 24. Math/reasoning activities • Examples of materials include puzzles, number games, dominoes, Veritec, board game, such as Chutes and Ladders. • For grade 1 and up, chess, checkers, Veritec, backgammon, dominoes, this category. • Variety of age-appropriate math/reasoning game and/or activities are accessible for free choice daily. At least 3-5 different games/activities shall be accessible. • Staff encourage children to practice math/reasoning skills in daily activities. Staff shall link math and numbers to practical life events in the children’s daily schedule. Use opportunities, such as meal time, counting number of children, transition times, use timer for taking turns, keeping scores in ball games, taking attendance by children, taking about times using clock, etc. 25. Science/nature activities • Equipment examples include aquarium, terrarium, measuring tools, magnifying glasses, magnets, scales, microscope. • Materials examples include natural objects, living things, realistic books, posters, pictures, and science games. • Special activities for extended opportunity to observe nature is offered at least twice a year. Examples are watching caterpillars turn into butterflies, planting and caring for a garden. 26 Cultural Awareness • At least four easily visible examples of different types of diversity must be present, other than gender. Examples are multi-cultural books, pictures of various countries and races, books in more than one language bilingual community, dolls or block accessory people of different races, ages. • In addition to cultural diversity, no inappropriate materials, such as pictures and books depicting males and females in non-traditional roles are visible. • Staff must display a non-biased approach to activities. For example, girls are encouraged to participate in carpentry, and boys are encouraged to participate in cooking. 28 Staff-Child interactions • Staff respond to children in a warm, supportive manner. Staff show respect for children. • For 7 pt level, staff shall support children and take the lead in selecting and initiating activities. 29 staff-child communication • Staff communicates with children frequently. • Children ask why, how and what if questions. • For 7 pts level, staff shall make effort to talk with each child and expand on ideas presented by children. 30 Staff supervision of children • Supervision shall be provided to all children, and the adjustment shall be made for younger and more challenging children to supervise them more closely. • Staff shall provide help and encouragement to children as needed. • Staff shall show appreciation of children’s effort and accomplishments. 36 Schedule • Flexibility is possible within the schedule • Both Staff-initiated and child-initiated activities shall be available. • Gross motor activities for all children outdoor shall be available daily (weather permitted). Gross motor activities: Daily outdoors for at least 30 minutes for programs operating 3+ hours unless severe weather prevents children from going outdoors. Provisions must also be made indoors for the same amount of time on those days when children cannot play outdoors. Overall access to stationary gross motor equipment throughout the week; equipment must offer at least 5 play possibilities (monkey bars, slide, tunnel, balance beam, playing basketball, etc.). Children must have access to some stationary equipment daily, weather permitting, and must have access to stationary gross motor equipment that provides a variety of play opportunities over the course of the week. Stationary gross motor equipment must be provided that stimulates at least 5 different skills overall for the observed group, and all children in the group must have some appropriate equipment. To score this indicator, look at children’s overall access to stationary gross motor equipment throughout the week. The portable equipment must be accessible daily and stimulate 5 different skills. On days when children do not go outside, these materials must be provided indoors. Portable gross motor equipment is provided that stimulates at least 5 different skills overall for the observed group, with some choice in materials. Consultation: Health Questionnaire The Health questionnaire is required for the second year of employment and must be updated annually thereafter. 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 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. 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 kaoru.eddins@dhhs.nc.gov or 828.556.9013 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