West Asheville Academy

10A NCAC 09 .2818 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0526-073L Visit Date: 5/13/2026 Number Present: 31 Completed Date: 5/13/2026 Age: From 0 To 5 Total Minutes: 268 Time In: 09:32 AM Time Out: 02:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. 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 Kathy Mashburn, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy-seven (77) percent as of today prior to this visit. The program operates with a four-star center license issued on 4/6/18 with restrictions; daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 5/6/26 and sent to me on the same day. In addition to addressing the allegations, permit restrictions, staff/child ratios, discipline, and adequate space. Allegations within the report included the following: *Safe environment was not provided for children. *Parent or guardian of child was not allowed access to the center during operating hours. Allegations regarding safe environments pertain to staff members allowing children to engage in physical conflicts. Additionally, an individual who is not a child care staff or a parent/guardian was allowed to be present in the facility during business hours. Additionally, allegations for parental access is for the program not allowing parents to come in the facility. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn did not accompany me on the walkthrough of the center due to preparing lunch and substituting in the classroom to maintain staff/child ratios as needed. Walk-through: In space #1, six (6) children, infants and one (1) year of age, were present with two (2) staff members. One (1) child was in a center exploring materials by putting them in his/her mouth. One of the staff members removed the mouthed toys as needed and put them in the dirty toy bin. Other children gathered around the other staff member and sang songs. In space #2, a group of seven (7) children, all two (2) years of age, were present with one (1) staff member. One (1) child played in a block center with toy vehicles and others played in the housekeeping center. Children’s songs were playing in loud volume in the background. During observation, one (1) staff member from space #3 came in with one (1) child and changed the child’s diaper on the changing table. During this time, Ms. Mashburn was in space #3 and maintained the staff/child ratios. In space #3, a group of seventeen (17) children, two-to-five years of age, were present with two (2) staff members. One (1) of seventeen (17) children was a child of a staff member, who was four (4) years of age. The child was present due to his/her child care center being closed. At 10:25 am, one (1) child, three (3) years of age, was dropped off and joined the rest of the children in space #3 – which made it a total of eighteen (18) children. The children engaged in free play with dress up clothes, dolls, bristle blocks, potato heads, soft blocks, people accessories, toy animals, puzzles, dominos and other manipulative materials. One (1) child was asleep in the book/quiet area on a child size floor chair/sofa. Around 10:15 am, one (1) staff member from space #1 came out and talked with Ms. Mashburn. Before the staff member returned to space #1, he/she brought a child out of space #1 and returned to space #1 with the child. The child, who was one (1) year of age, briefly joined space #2. Ms. Mashburn stated that she was in space #2 to maintain the ratios but came out to check on the lunch. At the time I observed the incident, there were five (5) children, infants and one (1) year of age, present with one (1) staff member in space #1, and there were eight (8) children, one (1) and two (2) year of age, with one (1) staff member in space #2. The staff/child ratios for one (1) year old for this program is 1:6. Investigation: Regarding allegations that staff members allow children to fight, peer interactions and staff/child interactions were observed in Spaces #2 and #3. In Space #2, six (6) children played in the housekeeping center with baby dolls, pretend food, and other materials. One (1) child threw a toy bin onto the floor. The staff member, who was seated near the housekeeping center, stated, “Please don’t throw the bin. I don’t like it.” During play, one (1) child picked up a pair of pretend medical scissors. Another child became upset and grabbed the child who had the scissors. The staff member intervened. The child pointed to the scissors and looked at the staff member. The staff member spoke with the child; however, details of the conversation could not be heard due to music playing in the classroom. The staff member redirected the child to use pretend shots instead, and the child complied. Later, two (2) children had conflicts over toys and turns on two (2) separate occasions. On both occasions, the staff member redirected the children successfully. Several children later moved to the block area, where three (3) children played with toy vehicles, pretend people, and blocks. One (1) child used a toy vehicle to knock down a toy person another child was using. The child playing with the toy person screamed. The staff member, who remained seated near the housekeeping center adjacent to the block area, asked what had happened and stated that he/she would “come look.” At the same time, the staff member announced that clean-up time would begin in a few minutes. Before the staff member moved to the block center, one (1) child who was playing with toy people hit, with his/her hand, the child who was playing with the toy truck. The child who had been hit walked to the staff member and pointed to the other child. The staff member asked what had happened; however, the child continued pointing and did not verbally respond. The staff member encouraged the child to use words, but the child did not speak. The staff member then joined the group in the block area and engaged with the children using the materials. The children joined the staff member in play shortly afterward. In Space #3, children were actively engaged in free play. One (1) staff member was positioned near the entrance, while the other staff member was positioned near the back door leading to the playground. Five (5) children were present in the housekeeping area, supervised by the staff member positioned near the entrance. During play, two (2) children engaged in pushing each other back and forth. The staff member called one (1) of the children involved, along with another child who had not been involved in the pushing, to him/her and spoke with them calmly about the situation. One (1) child in the block area displayed active behavior during the observation period. The child ran, jumped in the open space near the housekeeping center, and climbed/hung on the housekeeping shelves multiple times. The staff member positioned near the entrance verbally redirected the child from a distance on two (2) occasions, instructing the child to keep his/her feet on the floor. Each time, the child complied briefly before repeating the behavior several times during the observation period. The program’s incident reports and incident log were reviewed. There were nine (9) incidents documented for the program between April 15, 2026 – May 6, 2026. Out of nine (9) incidents, three (3) incident occurred due to conflicts among children – two (2) biting incident, , and one (1) hitting incident. Regarding allegations of maintaining a safe environment where non-staff members or parents/guardians were allowed to be present on the premises, all staff members present during today’s visit were interviewed. Staff members stated that the only individual occasionally present at the facility was the spouse of Ms. Mashburn, owner/operator/administrator of the program. Staff members stated that this individual comes to the center to repair equipment or assist with tasks requiring physical labor. Based on the duties performed at the facility, this individual would be considered a volunteer. Ms. Mashburn stated that on other occasions, staff members’ relatives or acquaintances had briefly entered the facility to drop off drinks. Ms. Mashburn stated that the individuals entered the kitchen area, left the drinks, and exited the facility immediately afterward. Based on the observation and interviews conducted, the allegation regarding maintaining a safe environment was determined to be unsubstantiated. Staff members were observed responding to and attempting behavioral management strategies during incidents of peer conflict. Teacher training on behavioral management and classroom set up is recommended. Additionally, staff members stated that any visiting individuals on the premises do not remain without a purpose and are not counted in staff-to-child ratios. Investigation: Parent Access All staff members were interviewed regarding parent access to the facility. Each staff member was interviewed independently; however, each provided consistent statements. Staff members reported that one (1) designated staff member answers the door to receive children from parents/guardians. This procedure is intended to reduce the spread of germs and to minimize potentially disruptive situations during transitions. Staff members further stated that parents/guardians are permitted to enter the facility upon request and with approval from Ms. Mashburn. Based on the interviews conducted and the absence of additional evidence, the allegation regarding denial of parent access to the center was unsubstantiated. However, I strongly recommend the program's policies on access to the facility with all participating parties. The following violations were documented during today’s visit: Violation Number Comment Rule 1328 Children's records were not made available for review. One (1) child, who was four (4) years of age, were present in space #3. The child was a staff member's child, and he/she was present due to his/her child care center being closed. G.S. 110-91(9) 1756 Enhanced staff/child ratios and group sizes were not met. Approximately five (5) minutes around 10:20 am, one (1) staff member was responsible for a group of eight (8) children, one (1) to two (2) years of age in space #2. 10A NCAC 09 .2818 Technical assistance was provided as follows: 1328: Children’s record Children records must be available for review. To comply, please create a folder for staff member’s child and add all required documents. Children who are not enrolled in the program cannot be present at the facility – meaning all children present at the facility must be enrolled. Staff members are working to take care of children at the facility. Therefore, he/she shall act accordingly to follow the program’s operational policies. Please review this requirement with your staff members. In your compliance letter, please verify the completion of this task. 1756: Enhanced staff/child ratios Enhanced staff/child ratios must be met at all times To comply, each staff member must be aware of staff/child ratio requirements and comply at all times. Please review the staff/child ratio requirements with your staff members. This violation requires a follow-up visit. Therefore, you are not required to submit a compliance statement. Achieving Compliance: The facility received a violation regarding staff/child ratios today. A follow-up visit will be conducted in the near future to determine if staff/child ratios are maintained. The violations documented above, must be corrected immediately. Please send me a compliance letter describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. This pertains to violations items that do not require a follow-up visit. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/27/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Dirt/Sand in Hair: It is common for children to have dirt or sand in their hair as a result of play. While it is not possible to prevent children from playing with dirt or sand, it is possible to reduce instances in which dirt or sand gets in children’s hair. I encourage communication with parents to determine whether they can provide a hat or bandana for children to wear during outdoor play. Additionally, staff should provide children with learning opportunities throughout the year to discuss respecting peers and controlling their actions. Exclusion of children: Child care program may follow the program’s exclusion policy for illness. Below is the link that explains the exclusion guideline in details: https://ncchildcare.ncdhhs.gov/Files?portalid=0&file=documents%2fpdf%2fC%2fCommunicable_Diseases_and_Exclusion.pdf Parents/guardians are encouraged to access this information as well as program’s illness/exclusion policy. When policies are unclear, parents/guardian shall be able to discuss clarification with the program’s administrator. When children are excluded for illness, documentations of temperature, vomiting, diarrhea, etc. are strongly recommended to communicate with parents/guardians (e.g., 101.5 degrees at 10:15 am, 101.8 degrees at 12:00 pm, etc.) Appropriate sleeping apparatus: When a child falls asleep, the child shall be moved to appropriate sleeping apparatus at earliest opportunities possible. Sleeping child shall be closely monitored while being asleep. Volunteers: Volunteers must complete the following if he/she comes during business hours: • Verification of age • TB screening • Emergency information form • Health Questionnaire • Documentation of being informed of EPR plan and its location. Behavioral Management: Even though staff members addressed most of the situations that occur in the classroom during today’s visit, additional teacher training and modifications in the classroom is recommended. 1. Classroom setting – In space #2 and #3, each center is small and are not recommended for three (3) or more children to adequately play without conflicts. Small centers creates bodies to bump into one another and often creates frustration. Identify popular centers and expand the space. Some manipulatives are recommended for table play. make tables available for some materials to reduce clutter and tripping hazard. Open space allows children to engage in active play. To reduce such action, you have to minimize long/large open space. 2. Behavioral management – For children who are two (2) years of age, often do not have adequate language to express themselves. Staff shall model what they are trying to say and provide them with tools to express themselves, such as visual aid. Re-directing is developmentally appropriate for children who are two (2). At the same time, preventing undesired behaviors are important by preparing enough materials for all children so that they do not fight over few toys. Additionally, expand space of popular centers so that they have more space to move around. For children three (3) and above, staff member shall talk to them in close proximity. When children are talked to from distance, they often do not hear or ignore. When staff member limit children’s actions, he/she must provide them with alternative actions as well as reasons why they cannot engage in the actions. For example, running inside is dangerous. You could fall and get hurt since many toys are on the floor. You can run on the playground. For older children, ask open-ended questions to facilitate conversations. For example, why do you think you cannot run in the classroom? Where can we run instead? 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 e 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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. 110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0526-073L Visit Date: 5/13/2026 Number Present: 31 Completed Date: 5/13/2026 Age: From 0 To 5 Total Minutes: 268 Time In: 09:32 AM Time Out: 02:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. 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 Kathy Mashburn, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy-seven (77) percent as of today prior to this visit. The program operates with a four-star center license issued on 4/6/18 with restrictions; daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 5/6/26 and sent to me on the same day. In addition to addressing the allegations, permit restrictions, staff/child ratios, discipline, and adequate space. Allegations within the report included the following: *Safe environment was not provided for children. *Parent or guardian of child was not allowed access to the center during operating hours. Allegations regarding safe environments pertain to staff members allowing children to engage in physical conflicts. Additionally, an individual who is not a child care staff or a parent/guardian was allowed to be present in the facility during business hours. Additionally, allegations for parental access is for the program not allowing parents to come in the facility. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn did not accompany me on the walkthrough of the center due to preparing lunch and substituting in the classroom to maintain staff/child ratios as needed. Walk-through: In space #1, six (6) children, infants and one (1) year of age, were present with two (2) staff members. One (1) child was in a center exploring materials by putting them in his/her mouth. One of the staff members removed the mouthed toys as needed and put them in the dirty toy bin. Other children gathered around the other staff member and sang songs. In space #2, a group of seven (7) children, all two (2) years of age, were present with one (1) staff member. One (1) child played in a block center with toy vehicles and others played in the housekeeping center. Children’s songs were playing in loud volume in the background. During observation, one (1) staff member from space #3 came in with one (1) child and changed the child’s diaper on the changing table. During this time, Ms. Mashburn was in space #3 and maintained the staff/child ratios. In space #3, a group of seventeen (17) children, two-to-five years of age, were present with two (2) staff members. One (1) of seventeen (17) children was a child of a staff member, who was four (4) years of age. The child was present due to his/her child care center being closed. At 10:25 am, one (1) child, three (3) years of age, was dropped off and joined the rest of the children in space #3 – which made it a total of eighteen (18) children. The children engaged in free play with dress up clothes, dolls, bristle blocks, potato heads, soft blocks, people accessories, toy animals, puzzles, dominos and other manipulative materials. One (1) child was asleep in the book/quiet area on a child size floor chair/sofa. Around 10:15 am, one (1) staff member from space #1 came out and talked with Ms. Mashburn. Before the staff member returned to space #1, he/she brought a child out of space #1 and returned to space #1 with the child. The child, who was one (1) year of age, briefly joined space #2. Ms. Mashburn stated that she was in space #2 to maintain the ratios but came out to check on the lunch. At the time I observed the incident, there were five (5) children, infants and one (1) year of age, present with one (1) staff member in space #1, and there were eight (8) children, one (1) and two (2) year of age, with one (1) staff member in space #2. The staff/child ratios for one (1) year old for this program is 1:6. Investigation: Regarding allegations that staff members allow children to fight, peer interactions and staff/child interactions were observed in Spaces #2 and #3. In Space #2, six (6) children played in the housekeeping center with baby dolls, pretend food, and other materials. One (1) child threw a toy bin onto the floor. The staff member, who was seated near the housekeeping center, stated, “Please don’t throw the bin. I don’t like it.” During play, one (1) child picked up a pair of pretend medical scissors. Another child became upset and grabbed the child who had the scissors. The staff member intervened. The child pointed to the scissors and looked at the staff member. The staff member spoke with the child; however, details of the conversation could not be heard due to music playing in the classroom. The staff member redirected the child to use pretend shots instead, and the child complied. Later, two (2) children had conflicts over toys and turns on two (2) separate occasions. On both occasions, the staff member redirected the children successfully. Several children later moved to the block area, where three (3) children played with toy vehicles, pretend people, and blocks. One (1) child used a toy vehicle to knock down a toy person another child was using. The child playing with the toy person screamed. The staff member, who remained seated near the housekeeping center adjacent to the block area, asked what had happened and stated that he/she would “come look.” At the same time, the staff member announced that clean-up time would begin in a few minutes. Before the staff member moved to the block center, one (1) child who was playing with toy people hit, with his/her hand, the child who was playing with the toy truck. The child who had been hit walked to the staff member and pointed to the other child. The staff member asked what had happened; however, the child continued pointing and did not verbally respond. The staff member encouraged the child to use words, but the child did not speak. The staff member then joined the group in the block area and engaged with the children using the materials. The children joined the staff member in play shortly afterward. In Space #3, children were actively engaged in free play. One (1) staff member was positioned near the entrance, while the other staff member was positioned near the back door leading to the playground. Five (5) children were present in the housekeeping area, supervised by the staff member positioned near the entrance. During play, two (2) children engaged in pushing each other back and forth. The staff member called one (1) of the children involved, along with another child who had not been involved in the pushing, to him/her and spoke with them calmly about the situation. One (1) child in the block area displayed active behavior during the observation period. The child ran, jumped in the open space near the housekeeping center, and climbed/hung on the housekeeping shelves multiple times. The staff member positioned near the entrance verbally redirected the child from a distance on two (2) occasions, instructing the child to keep his/her feet on the floor. Each time, the child complied briefly before repeating the behavior several times during the observation period. The program’s incident reports and incident log were reviewed. There were nine (9) incidents documented for the program between April 15, 2026 – May 6, 2026. Out of nine (9) incidents, three (3) incident occurred due to conflicts among children – two (2) biting incident, , and one (1) hitting incident. Regarding allegations of maintaining a safe environment where non-staff members or parents/guardians were allowed to be present on the premises, all staff members present during today’s visit were interviewed. Staff members stated that the only individual occasionally present at the facility was the spouse of Ms. Mashburn, owner/operator/administrator of the program. Staff members stated that this individual comes to the center to repair equipment or assist with tasks requiring physical labor. Based on the duties performed at the facility, this individual would be considered a volunteer. Ms. Mashburn stated that on other occasions, staff members’ relatives or acquaintances had briefly entered the facility to drop off drinks. Ms. Mashburn stated that the individuals entered the kitchen area, left the drinks, and exited the facility immediately afterward. Based on the observation and interviews conducted, the allegation regarding maintaining a safe environment was determined to be unsubstantiated. Staff members were observed responding to and attempting behavioral management strategies during incidents of peer conflict. Teacher training on behavioral management and classroom set up is recommended. Additionally, staff members stated that any visiting individuals on the premises do not remain without a purpose and are not counted in staff-to-child ratios. Investigation: Parent Access All staff members were interviewed regarding parent access to the facility. Each staff member was interviewed independently; however, each provided consistent statements. Staff members reported that one (1) designated staff member answers the door to receive children from parents/guardians. This procedure is intended to reduce the spread of germs and to minimize potentially disruptive situations during transitions. Staff members further stated that parents/guardians are permitted to enter the facility upon request and with approval from Ms. Mashburn. Based on the interviews conducted and the absence of additional evidence, the allegation regarding denial of parent access to the center was unsubstantiated. However, I strongly recommend the program's policies on access to the facility with all participating parties. The following violations were documented during today’s visit: Violation Number Comment Rule 1328 Children's records were not made available for review. One (1) child, who was four (4) years of age, were present in space #3. The child was a staff member's child, and he/she was present due to his/her child care center being closed. G.S. 110-91(9) 1756 Enhanced staff/child ratios and group sizes were not met. Approximately five (5) minutes around 10:20 am, one (1) staff member was responsible for a group of eight (8) children, one (1) to two (2) years of age in space #2. 10A NCAC 09 .2818 Technical assistance was provided as follows: 1328: Children’s record Children records must be available for review. To comply, please create a folder for staff member’s child and add all required documents. Children who are not enrolled in the program cannot be present at the facility – meaning all children present at the facility must be enrolled. Staff members are working to take care of children at the facility. Therefore, he/she shall act accordingly to follow the program’s operational policies. Please review this requirement with your staff members. In your compliance letter, please verify the completion of this task. 1756: Enhanced staff/child ratios Enhanced staff/child ratios must be met at all times To comply, each staff member must be aware of staff/child ratio requirements and comply at all times. Please review the staff/child ratio requirements with your staff members. This violation requires a follow-up visit. Therefore, you are not required to submit a compliance statement. Achieving Compliance: The facility received a violation regarding staff/child ratios today. A follow-up visit will be conducted in the near future to determine if staff/child ratios are maintained. The violations documented above, must be corrected immediately. Please send me a compliance letter describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. This pertains to violations items that do not require a follow-up visit. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/27/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Dirt/Sand in Hair: It is common for children to have dirt or sand in their hair as a result of play. While it is not possible to prevent children from playing with dirt or sand, it is possible to reduce instances in which dirt or sand gets in children’s hair. I encourage communication with parents to determine whether they can provide a hat or bandana for children to wear during outdoor play. Additionally, staff should provide children with learning opportunities throughout the year to discuss respecting peers and controlling their actions. Exclusion of children: Child care program may follow the program’s exclusion policy for illness. Below is the link that explains the exclusion guideline in details: https://ncchildcare.ncdhhs.gov/Files?portalid=0&file=documents%2fpdf%2fC%2fCommunicable_Diseases_and_Exclusion.pdf Parents/guardians are encouraged to access this information as well as program’s illness/exclusion policy. When policies are unclear, parents/guardian shall be able to discuss clarification with the program’s administrator. When children are excluded for illness, documentations of temperature, vomiting, diarrhea, etc. are strongly recommended to communicate with parents/guardians (e.g., 101.5 degrees at 10:15 am, 101.8 degrees at 12:00 pm, etc.) Appropriate sleeping apparatus: When a child falls asleep, the child shall be moved to appropriate sleeping apparatus at earliest opportunities possible. Sleeping child shall be closely monitored while being asleep. Volunteers: Volunteers must complete the following if he/she comes during business hours: • Verification of age • TB screening • Emergency information form • Health Questionnaire • Documentation of being informed of EPR plan and its location. Behavioral Management: Even though staff members addressed most of the situations that occur in the classroom during today’s visit, additional teacher training and modifications in the classroom is recommended. 1. Classroom setting – In space #2 and #3, each center is small and are not recommended for three (3) or more children to adequately play without conflicts. Small centers creates bodies to bump into one another and often creates frustration. Identify popular centers and expand the space. Some manipulatives are recommended for table play. make tables available for some materials to reduce clutter and tripping hazard. Open space allows children to engage in active play. To reduce such action, you have to minimize long/large open space. 2. Behavioral management – For children who are two (2) years of age, often do not have adequate language to express themselves. Staff shall model what they are trying to say and provide them with tools to express themselves, such as visual aid. Re-directing is developmentally appropriate for children who are two (2). At the same time, preventing undesired behaviors are important by preparing enough materials for all children so that they do not fight over few toys. Additionally, expand space of popular centers so that they have more space to move around. For children three (3) and above, staff member shall talk to them in close proximity. When children are talked to from distance, they often do not hear or ignore. When staff member limit children’s actions, he/she must provide them with alternative actions as well as reasons why they cannot engage in the actions. For example, running inside is dangerous. You could fall and get hurt since many toys are on the floor. You can run on the playground. For older children, ask open-ended questions to facilitate conversations. For example, why do you think you cannot run in the classroom? Where can we run instead? 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 e 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0526-073L Visit Date: 5/13/2026 Number Present: 31 Completed Date: 5/13/2026 Age: From 0 To 5 Total Minutes: 268 Time In: 09:32 AM Time Out: 02:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. 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 Kathy Mashburn, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy-seven (77) percent as of today prior to this visit. The program operates with a four-star center license issued on 4/6/18 with restrictions; daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 5/6/26 and sent to me on the same day. In addition to addressing the allegations, permit restrictions, staff/child ratios, discipline, and adequate space. Allegations within the report included the following: *Safe environment was not provided for children. *Parent or guardian of child was not allowed access to the center during operating hours. Allegations regarding safe environments pertain to staff members allowing children to engage in physical conflicts. Additionally, an individual who is not a child care staff or a parent/guardian was allowed to be present in the facility during business hours. Additionally, allegations for parental access is for the program not allowing parents to come in the facility. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn did not accompany me on the walkthrough of the center due to preparing lunch and substituting in the classroom to maintain staff/child ratios as needed. Walk-through: In space #1, six (6) children, infants and one (1) year of age, were present with two (2) staff members. One (1) child was in a center exploring materials by putting them in his/her mouth. One of the staff members removed the mouthed toys as needed and put them in the dirty toy bin. Other children gathered around the other staff member and sang songs. In space #2, a group of seven (7) children, all two (2) years of age, were present with one (1) staff member. One (1) child played in a block center with toy vehicles and others played in the housekeeping center. Children’s songs were playing in loud volume in the background. During observation, one (1) staff member from space #3 came in with one (1) child and changed the child’s diaper on the changing table. During this time, Ms. Mashburn was in space #3 and maintained the staff/child ratios. In space #3, a group of seventeen (17) children, two-to-five years of age, were present with two (2) staff members. One (1) of seventeen (17) children was a child of a staff member, who was four (4) years of age. The child was present due to his/her child care center being closed. At 10:25 am, one (1) child, three (3) years of age, was dropped off and joined the rest of the children in space #3 – which made it a total of eighteen (18) children. The children engaged in free play with dress up clothes, dolls, bristle blocks, potato heads, soft blocks, people accessories, toy animals, puzzles, dominos and other manipulative materials. One (1) child was asleep in the book/quiet area on a child size floor chair/sofa. Around 10:15 am, one (1) staff member from space #1 came out and talked with Ms. Mashburn. Before the staff member returned to space #1, he/she brought a child out of space #1 and returned to space #1 with the child. The child, who was one (1) year of age, briefly joined space #2. Ms. Mashburn stated that she was in space #2 to maintain the ratios but came out to check on the lunch. At the time I observed the incident, there were five (5) children, infants and one (1) year of age, present with one (1) staff member in space #1, and there were eight (8) children, one (1) and two (2) year of age, with one (1) staff member in space #2. The staff/child ratios for one (1) year old for this program is 1:6. Investigation: Regarding allegations that staff members allow children to fight, peer interactions and staff/child interactions were observed in Spaces #2 and #3. In Space #2, six (6) children played in the housekeeping center with baby dolls, pretend food, and other materials. One (1) child threw a toy bin onto the floor. The staff member, who was seated near the housekeeping center, stated, “Please don’t throw the bin. I don’t like it.” During play, one (1) child picked up a pair of pretend medical scissors. Another child became upset and grabbed the child who had the scissors. The staff member intervened. The child pointed to the scissors and looked at the staff member. The staff member spoke with the child; however, details of the conversation could not be heard due to music playing in the classroom. The staff member redirected the child to use pretend shots instead, and the child complied. Later, two (2) children had conflicts over toys and turns on two (2) separate occasions. On both occasions, the staff member redirected the children successfully. Several children later moved to the block area, where three (3) children played with toy vehicles, pretend people, and blocks. One (1) child used a toy vehicle to knock down a toy person another child was using. The child playing with the toy person screamed. The staff member, who remained seated near the housekeeping center adjacent to the block area, asked what had happened and stated that he/she would “come look.” At the same time, the staff member announced that clean-up time would begin in a few minutes. Before the staff member moved to the block center, one (1) child who was playing with toy people hit, with his/her hand, the child who was playing with the toy truck. The child who had been hit walked to the staff member and pointed to the other child. The staff member asked what had happened; however, the child continued pointing and did not verbally respond. The staff member encouraged the child to use words, but the child did not speak. The staff member then joined the group in the block area and engaged with the children using the materials. The children joined the staff member in play shortly afterward. In Space #3, children were actively engaged in free play. One (1) staff member was positioned near the entrance, while the other staff member was positioned near the back door leading to the playground. Five (5) children were present in the housekeeping area, supervised by the staff member positioned near the entrance. During play, two (2) children engaged in pushing each other back and forth. The staff member called one (1) of the children involved, along with another child who had not been involved in the pushing, to him/her and spoke with them calmly about the situation. One (1) child in the block area displayed active behavior during the observation period. The child ran, jumped in the open space near the housekeeping center, and climbed/hung on the housekeeping shelves multiple times. The staff member positioned near the entrance verbally redirected the child from a distance on two (2) occasions, instructing the child to keep his/her feet on the floor. Each time, the child complied briefly before repeating the behavior several times during the observation period. The program’s incident reports and incident log were reviewed. There were nine (9) incidents documented for the program between April 15, 2026 – May 6, 2026. Out of nine (9) incidents, three (3) incident occurred due to conflicts among children – two (2) biting incident, , and one (1) hitting incident. Regarding allegations of maintaining a safe environment where non-staff members or parents/guardians were allowed to be present on the premises, all staff members present during today’s visit were interviewed. Staff members stated that the only individual occasionally present at the facility was the spouse of Ms. Mashburn, owner/operator/administrator of the program. Staff members stated that this individual comes to the center to repair equipment or assist with tasks requiring physical labor. Based on the duties performed at the facility, this individual would be considered a volunteer. Ms. Mashburn stated that on other occasions, staff members’ relatives or acquaintances had briefly entered the facility to drop off drinks. Ms. Mashburn stated that the individuals entered the kitchen area, left the drinks, and exited the facility immediately afterward. Based on the observation and interviews conducted, the allegation regarding maintaining a safe environment was determined to be unsubstantiated. Staff members were observed responding to and attempting behavioral management strategies during incidents of peer conflict. Teacher training on behavioral management and classroom set up is recommended. Additionally, staff members stated that any visiting individuals on the premises do not remain without a purpose and are not counted in staff-to-child ratios. Investigation: Parent Access All staff members were interviewed regarding parent access to the facility. Each staff member was interviewed independently; however, each provided consistent statements. Staff members reported that one (1) designated staff member answers the door to receive children from parents/guardians. This procedure is intended to reduce the spread of germs and to minimize potentially disruptive situations during transitions. Staff members further stated that parents/guardians are permitted to enter the facility upon request and with approval from Ms. Mashburn. Based on the interviews conducted and the absence of additional evidence, the allegation regarding denial of parent access to the center was unsubstantiated. However, I strongly recommend the program's policies on access to the facility with all participating parties. The following violations were documented during today’s visit: Violation Number Comment Rule 1328 Children's records were not made available for review. One (1) child, who was four (4) years of age, were present in space #3. The child was a staff member's child, and he/she was present due to his/her child care center being closed. G.S. 110-91(9) 1756 Enhanced staff/child ratios and group sizes were not met. Approximately five (5) minutes around 10:20 am, one (1) staff member was responsible for a group of eight (8) children, one (1) to two (2) years of age in space #2. 10A NCAC 09 .2818 Technical assistance was provided as follows: 1328: Children’s record Children records must be available for review. To comply, please create a folder for staff member’s child and add all required documents. Children who are not enrolled in the program cannot be present at the facility – meaning all children present at the facility must be enrolled. Staff members are working to take care of children at the facility. Therefore, he/she shall act accordingly to follow the program’s operational policies. Please review this requirement with your staff members. In your compliance letter, please verify the completion of this task. 1756: Enhanced staff/child ratios Enhanced staff/child ratios must be met at all times To comply, each staff member must be aware of staff/child ratio requirements and comply at all times. Please review the staff/child ratio requirements with your staff members. This violation requires a follow-up visit. Therefore, you are not required to submit a compliance statement. Achieving Compliance: The facility received a violation regarding staff/child ratios today. A follow-up visit will be conducted in the near future to determine if staff/child ratios are maintained. The violations documented above, must be corrected immediately. Please send me a compliance letter describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. This pertains to violations items that do not require a follow-up visit. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/27/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Dirt/Sand in Hair: It is common for children to have dirt or sand in their hair as a result of play. While it is not possible to prevent children from playing with dirt or sand, it is possible to reduce instances in which dirt or sand gets in children’s hair. I encourage communication with parents to determine whether they can provide a hat or bandana for children to wear during outdoor play. Additionally, staff should provide children with learning opportunities throughout the year to discuss respecting peers and controlling their actions. Exclusion of children: Child care program may follow the program’s exclusion policy for illness. Below is the link that explains the exclusion guideline in details: https://ncchildcare.ncdhhs.gov/Files?portalid=0&file=documents%2fpdf%2fC%2fCommunicable_Diseases_and_Exclusion.pdf Parents/guardians are encouraged to access this information as well as program’s illness/exclusion policy. When policies are unclear, parents/guardian shall be able to discuss clarification with the program’s administrator. When children are excluded for illness, documentations of temperature, vomiting, diarrhea, etc. are strongly recommended to communicate with parents/guardians (e.g., 101.5 degrees at 10:15 am, 101.8 degrees at 12:00 pm, etc.) Appropriate sleeping apparatus: When a child falls asleep, the child shall be moved to appropriate sleeping apparatus at earliest opportunities possible. Sleeping child shall be closely monitored while being asleep. Volunteers: Volunteers must complete the following if he/she comes during business hours: • Verification of age • TB screening • Emergency information form • Health Questionnaire • Documentation of being informed of EPR plan and its location. Behavioral Management: Even though staff members addressed most of the situations that occur in the classroom during today’s visit, additional teacher training and modifications in the classroom is recommended. 1. Classroom setting – In space #2 and #3, each center is small and are not recommended for three (3) or more children to adequately play without conflicts. Small centers creates bodies to bump into one another and often creates frustration. Identify popular centers and expand the space. Some manipulatives are recommended for table play. make tables available for some materials to reduce clutter and tripping hazard. Open space allows children to engage in active play. To reduce such action, you have to minimize long/large open space. 2. Behavioral management – For children who are two (2) years of age, often do not have adequate language to express themselves. Staff shall model what they are trying to say and provide them with tools to express themselves, such as visual aid. Re-directing is developmentally appropriate for children who are two (2). At the same time, preventing undesired behaviors are important by preparing enough materials for all children so that they do not fight over few toys. Additionally, expand space of popular centers so that they have more space to move around. For children three (3) and above, staff member shall talk to them in close proximity. When children are talked to from distance, they often do not hear or ignore. When staff member limit children’s actions, he/she must provide them with alternative actions as well as reasons why they cannot engage in the actions. For example, running inside is dangerous. You could fall and get hurt since many toys are on the floor. You can run on the playground. For older children, ask open-ended questions to facilitate conversations. For example, why do you think you cannot run in the classroom? Where can we run instead? 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 e 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0901 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/30/2026 Number Present: 32 Completed Date: 4/30/2026 Age: From 0 To 4 Total Minutes: 204 Time In: 08:56 AM Time Out: 12:20 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during unannounced visit follow-up. 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn was available during the visit. Limited monitoring of child care requirements was conducted including the violations cited during routine unannounced visit conducted on April 21, 2026. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy-six (76) as of today prior to this visit. The program operates with a four-star center license issued on 4/6/18 with restrictions; daytime care, meets enhanced ratios and space. Upon arrival, I announced my presence and the purpose of the visit. At the time of arrival, there were seven (7) children, infants and ones with two (2) staff members in space #1, four (4) children, all twos, with one (1) staff member in space #2, and eleven (11) children, two-to-five years old, with two (2) staff members in space #3. Between 8:56 am – 9:40 am, a total of seven (7) additional children – one (1) child in space #2 and six (6) children in space #3 arrived. All children were adequately signed in upon their arrival by Ms. Mashburn. The attendance record indicated that two (2) children in space #2 were signed in but signed out shortly after. Per Ms. Mashburn, grandmother of the children took the children to the doctor and planned to bring them back. Their attendance record indicated the time the children were dropped off at the facility and the time they were picked up by the grandmother. Biscuits, apple sauce and milk were served for breakfast. On the menu posted in the kitchen, frosted mini wheats, blueberries and milk were listed. Ms. Mashburn wrote down correct items after breakfast was served. During this time, she corrected the lunch items to chicken and waffles, green beans and peaches. In space #1, a group of seven (7) children, infants and ones, were present. The children walked around, explored the environment and picked up toys. One (1) diaper cream was maintained in the classroom – Equate Diaper Rash Ointment. The permission form was on file. All cups and bottles in the refrigerator were labeled with children’s names and today’s date. No baby food in the cabinet by the door was expired. No hazardous products were accessible to the children. In space #2, a group of six (6) children, all twos, were present with one (1) staff member. The children played with pretend food, science materials and manipulatives. At 10:45 am, two (2) children, both two (2) years of age, were brought back to the classroom, making a total of children (8). In space #3, a group of seventeen (17) children, two-to-five years of age, were present with two (2) staff members. Two (2) children had breakfast at the table, while other children engaged in free play with puzzles, string and beads, toy people and cars, pretend kitchen tools and food, etc. One (1) staff member positioned by the table where children were eating, and the other staff member positioned by the door to the playground. Staff/child ratio sheet was posted by the entrance door. The correction of the following violation items were monitored: 842: administration of medication Albuterol was administered two (2) days in October 2025 (10/7/25 and 10/8/25). During the routine unannounced visit, medication authorization form was not present for review. The staff members in space #1 stated that the parent had brought the form with the medication when it was brought in but couldn’t not be located. During today’s visit, Ms. Mashburn stated that she reviewed the rule 10A NCAC 09 .0803(1)(a & b) and understood that no medications could be administered for children without parents’ signature on the permission form (medication authorization form). Albuterol was not present in space #1. Ms. Mashburn stated that the medication was sent home until the parent could submit the action plan and medication authorization form. With Ms. Mashburn’s statement, this item was marked corrected by consultant visit. 847: medication authorization form This violation was cited due to lack of medication authorization forms for A+D Prevent and Head and Maty’s Baby Multi-purpose ointment. In the compliance statement submitted on April 27, 2026, Ms. Mashburn stated that those products were removed. Neither one of the products were observed in space #1 during today’s visit. Therefore, this item was corrected by consultant visit. 849: Left over medications Destin diaper cream and Zinc Oxide Ointment in space #1 were returned home or discarded, per Ms. Mashburn. No Destin diaper cream or Zinc Oxide Ointment was observed in space #1 during today’s visit. Therefore, correction was verified during today’s visit and marked corrected by consultant visit. 1032: Medical statement A violation was cited on April 21, 2026, due to a staff member employed on 3/16/26 did not receive adequate signature, name of health care professional, address and phone number on the medical statement. One (1) staff member’s file was reviewed for medical statement. Medical statement was completed on 4/25/26 at Novant Health Go-Health Urgent Care in Asheville. A physician’s signature and the stamped name/address of the urgent care was on the form. With verification of the form being present in the staff file, this item was marked corrected by consultant visit. 1033: TB A violation was cited on April 21, 2026, due to a staff member employed on 3/16/26 did not receive adequate signature, name of health care professional, address and phone number on the TB screening form. One (1) staff member’s file was reviewed for TB screening. TB screen was completed on 4/25/26 at Novant Health Go-Health Urgent Care in Asheville. A physician’s signature and the stamped name/address of the urgent care was on the form. With verification of the form being present in the staff file, this item was marked corrected by consultant visit. 1045: 6-week orientation 1067: 2-week orientation I reviewed seven (7) staff files and verified that orientation sheet for staff members were adequately completed for both 2-weeks and 6-weeks orientation during today’s visit. Therefore, the correction of items 1045 and 1067 were verified and marked corrected by consultant visit. 1756: enhanced staff/child ratios As noted under observation, enhanced staff/child ratios were met during today’s visit in all classrooms. Therefore, correction of item 1756 was verified during today’s visit and marked corrected by consultant visit. 1834: Action plan Action plan for Albuterol in space #1 was not obtained yet. This violation cannot be corrected until action plans are on file for the child. When you obtain the action plan for the child in space #1 with chronic lung condition, please notify me. Per Ms. Mashburn, she is expecting the parent to bring the form by the end of today. 1848: Tobacco products Ms. Mashburn stated in the compliance letter submitted on April 27, 2026, that the parent with vaping device was reminded of the rules. No tobacco products were observed during today’s visit. Therefore, this item was marked corrected by consultant visit. 1882: Authorization form This violation was cited due to lack of parent’s signature on the medication authorization form for Albuterol in space #1. During today’s visit, albuterol was not present in space #1, the authorization form or action plan was present. Due to no medication, no authorization form was required. Therefore, this violation was marked corrected by consultant visit. I discussed the need for medication authorization form with Ms. Mashburn if the parent brings the albuterol to school. 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 documented during today’s visit: Violation Number Comment Rule 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Biscuits, apple sauce and milk were served for breakfast while frosted mini wheats, blueberries and milk were listed on the menu. The substitutions were not recorded prior to serving children. 10A NCAC 09 .0901(b) The following technical assistance was provided: 528: substitution items When items rather than what are listed on the menu are served, those items must be documented on the menu prior to serving children. Menu must be posted where cooks and parents can see. Ms. Mashburn documented the correct breakfast items - biscuits, apple sauce and milk for today's menu. Additionally, she also documented chicken and waffle, green beans and peaches for lunch prior to lunchtime. Therefore, this item was marked corrected during visit. Achieving Compliance: Even though you have corrected all violations cited during today’s visit, there is one (1) outstanding item remains for the violations cited during routine unannounced visit conducted on April 21, 2026, - item 1834. This item cannot be marked corrected until you obtain the action plan for the child with albuterol in space #1. When you obtain the action plan with adequate signature and information, please notify me via email and verify that you obtained the action plan and was filed in the child’s file. This action must be completed on or prior to March 5, 2025. Please note that the compliance statement must be sent to me via email address registered to the Division or on the appropriate letterhead with your signature. 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: Compliance History Rate: During today’s visit, Ms. Mashburn and I discussed the program’s compliance history rate. Prior to today’s visit, the rate was seventy-six (76) percent. I explained that the rate is calculated for previous eighteen (18) months at the time of monitoring visits. Since the rate could change based on which eighteen (18) months period it is calculated based upon, it is important to consistently meet the child care laws and requirements to maintain adequate compliance rate. When compliance rate falls under seventy-five (75) percent, program will be considered for Administrative Action Provisional License. If you want to know your current compliance rate, you can contact me each time at kaoru.eddins@dhhs.nc.gov. USDA meal components: We discussed required number of components for each meal – three (3) components for breakfast, five (5) for lunch and two (2) for snacks. Water does not count toward one (1) component, but milk does. 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 .0803 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/30/2026 Number Present: 32 Completed Date: 4/30/2026 Age: From 0 To 4 Total Minutes: 204 Time In: 08:56 AM Time Out: 12:20 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during unannounced visit follow-up. 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn was available during the visit. Limited monitoring of child care requirements was conducted including the violations cited during routine unannounced visit conducted on April 21, 2026. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy-six (76) as of today prior to this visit. The program operates with a four-star center license issued on 4/6/18 with restrictions; daytime care, meets enhanced ratios and space. Upon arrival, I announced my presence and the purpose of the visit. At the time of arrival, there were seven (7) children, infants and ones with two (2) staff members in space #1, four (4) children, all twos, with one (1) staff member in space #2, and eleven (11) children, two-to-five years old, with two (2) staff members in space #3. Between 8:56 am – 9:40 am, a total of seven (7) additional children – one (1) child in space #2 and six (6) children in space #3 arrived. All children were adequately signed in upon their arrival by Ms. Mashburn. The attendance record indicated that two (2) children in space #2 were signed in but signed out shortly after. Per Ms. Mashburn, grandmother of the children took the children to the doctor and planned to bring them back. Their attendance record indicated the time the children were dropped off at the facility and the time they were picked up by the grandmother. Biscuits, apple sauce and milk were served for breakfast. On the menu posted in the kitchen, frosted mini wheats, blueberries and milk were listed. Ms. Mashburn wrote down correct items after breakfast was served. During this time, she corrected the lunch items to chicken and waffles, green beans and peaches. In space #1, a group of seven (7) children, infants and ones, were present. The children walked around, explored the environment and picked up toys. One (1) diaper cream was maintained in the classroom – Equate Diaper Rash Ointment. The permission form was on file. All cups and bottles in the refrigerator were labeled with children’s names and today’s date. No baby food in the cabinet by the door was expired. No hazardous products were accessible to the children. In space #2, a group of six (6) children, all twos, were present with one (1) staff member. The children played with pretend food, science materials and manipulatives. At 10:45 am, two (2) children, both two (2) years of age, were brought back to the classroom, making a total of children (8). In space #3, a group of seventeen (17) children, two-to-five years of age, were present with two (2) staff members. Two (2) children had breakfast at the table, while other children engaged in free play with puzzles, string and beads, toy people and cars, pretend kitchen tools and food, etc. One (1) staff member positioned by the table where children were eating, and the other staff member positioned by the door to the playground. Staff/child ratio sheet was posted by the entrance door. The correction of the following violation items were monitored: 842: administration of medication Albuterol was administered two (2) days in October 2025 (10/7/25 and 10/8/25). During the routine unannounced visit, medication authorization form was not present for review. The staff members in space #1 stated that the parent had brought the form with the medication when it was brought in but couldn’t not be located. During today’s visit, Ms. Mashburn stated that she reviewed the rule 10A NCAC 09 .0803(1)(a & b) and understood that no medications could be administered for children without parents’ signature on the permission form (medication authorization form). Albuterol was not present in space #1. Ms. Mashburn stated that the medication was sent home until the parent could submit the action plan and medication authorization form. With Ms. Mashburn’s statement, this item was marked corrected by consultant visit. 847: medication authorization form This violation was cited due to lack of medication authorization forms for A+D Prevent and Head and Maty’s Baby Multi-purpose ointment. In the compliance statement submitted on April 27, 2026, Ms. Mashburn stated that those products were removed. Neither one of the products were observed in space #1 during today’s visit. Therefore, this item was corrected by consultant visit. 849: Left over medications Destin diaper cream and Zinc Oxide Ointment in space #1 were returned home or discarded, per Ms. Mashburn. No Destin diaper cream or Zinc Oxide Ointment was observed in space #1 during today’s visit. Therefore, correction was verified during today’s visit and marked corrected by consultant visit. 1032: Medical statement A violation was cited on April 21, 2026, due to a staff member employed on 3/16/26 did not receive adequate signature, name of health care professional, address and phone number on the medical statement. One (1) staff member’s file was reviewed for medical statement. Medical statement was completed on 4/25/26 at Novant Health Go-Health Urgent Care in Asheville. A physician’s signature and the stamped name/address of the urgent care was on the form. With verification of the form being present in the staff file, this item was marked corrected by consultant visit. 1033: TB A violation was cited on April 21, 2026, due to a staff member employed on 3/16/26 did not receive adequate signature, name of health care professional, address and phone number on the TB screening form. One (1) staff member’s file was reviewed for TB screening. TB screen was completed on 4/25/26 at Novant Health Go-Health Urgent Care in Asheville. A physician’s signature and the stamped name/address of the urgent care was on the form. With verification of the form being present in the staff file, this item was marked corrected by consultant visit. 1045: 6-week orientation 1067: 2-week orientation I reviewed seven (7) staff files and verified that orientation sheet for staff members were adequately completed for both 2-weeks and 6-weeks orientation during today’s visit. Therefore, the correction of items 1045 and 1067 were verified and marked corrected by consultant visit. 1756: enhanced staff/child ratios As noted under observation, enhanced staff/child ratios were met during today’s visit in all classrooms. Therefore, correction of item 1756 was verified during today’s visit and marked corrected by consultant visit. 1834: Action plan Action plan for Albuterol in space #1 was not obtained yet. This violation cannot be corrected until action plans are on file for the child. When you obtain the action plan for the child in space #1 with chronic lung condition, please notify me. Per Ms. Mashburn, she is expecting the parent to bring the form by the end of today. 1848: Tobacco products Ms. Mashburn stated in the compliance letter submitted on April 27, 2026, that the parent with vaping device was reminded of the rules. No tobacco products were observed during today’s visit. Therefore, this item was marked corrected by consultant visit. 1882: Authorization form This violation was cited due to lack of parent’s signature on the medication authorization form for Albuterol in space #1. During today’s visit, albuterol was not present in space #1, the authorization form or action plan was present. Due to no medication, no authorization form was required. Therefore, this violation was marked corrected by consultant visit. I discussed the need for medication authorization form with Ms. Mashburn if the parent brings the albuterol to school. 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 documented during today’s visit: Violation Number Comment Rule 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Biscuits, apple sauce and milk were served for breakfast while frosted mini wheats, blueberries and milk were listed on the menu. The substitutions were not recorded prior to serving children. 10A NCAC 09 .0901(b) The following technical assistance was provided: 528: substitution items When items rather than what are listed on the menu are served, those items must be documented on the menu prior to serving children. Menu must be posted where cooks and parents can see. Ms. Mashburn documented the correct breakfast items - biscuits, apple sauce and milk for today's menu. Additionally, she also documented chicken and waffle, green beans and peaches for lunch prior to lunchtime. Therefore, this item was marked corrected during visit. Achieving Compliance: Even though you have corrected all violations cited during today’s visit, there is one (1) outstanding item remains for the violations cited during routine unannounced visit conducted on April 21, 2026, - item 1834. This item cannot be marked corrected until you obtain the action plan for the child with albuterol in space #1. When you obtain the action plan with adequate signature and information, please notify me via email and verify that you obtained the action plan and was filed in the child’s file. This action must be completed on or prior to March 5, 2025. Please note that the compliance statement must be sent to me via email address registered to the Division or on the appropriate letterhead with your signature. 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: Compliance History Rate: During today’s visit, Ms. Mashburn and I discussed the program’s compliance history rate. Prior to today’s visit, the rate was seventy-six (76) percent. I explained that the rate is calculated for previous eighteen (18) months at the time of monitoring visits. Since the rate could change based on which eighteen (18) months period it is calculated based upon, it is important to consistently meet the child care laws and requirements to maintain adequate compliance rate. When compliance rate falls under seventy-five (75) percent, program will be considered for Administrative Action Provisional License. If you want to know your current compliance rate, you can contact me each time at kaoru.eddins@dhhs.nc.gov. USDA meal components: We discussed required number of components for each meal – three (3) components for breakfast, five (5) for lunch and two (2) for snacks. Water does not count toward one (1) component, but milk does. 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 .0601 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0901 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0302 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0304 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0604 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0701 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0803 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .1102 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .1801 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .2818 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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.110-105 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 4/21/2026 Number Present: 23 Completed Date: 4/21/2026 Age: From 0 To 5 Total Minutes: 427 Time In: 09:08 AM Time Out: 04:15 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 and also signed by Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Mashburn 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 seventy-eight (78) percent as of today prior to this visit. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 11/4/25. The last fire drill was practiced on 3/13/26. The last shelter-in-place drill was practiced on 3/17/26. The last playground inspection was documented on 3/23/26. The last fire inspection was approved on 11/4/25. The last sanitation inspection was conducted on 1/28/26 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Experience Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Seven (7) staff members were listed on the Automated Criminal Background Check Management System (ABCMS) as of 4/20/26. Upon arrival, I rang the doorbell and was admitted by Ms. Mashburn. I announced my presence and the purpose of the visit. Space #1: Six (6) children were present with one (1) staff member and Ms. Mashburn. One (1) infant was seated in a foam infant seat and was being fed baby food (sweet potatoes), while the other five (5) children, all one (1) year of age, engaged in play. Children were observed walking around the room, placing toy figures in their mouths, sitting in an adult rocking chair, and playing with rattles, books, and other materials. Staff member stated that a parent brought the sweet potatoes in the morning of 4/21/25 (today). As additional children arrived, parents rang the doorbell. Ms. Mashburn exited Space #1 each time to allow entry. During these periods, one (1) staff member was solely responsible for six (6) children until an additional staff member arrived at 9:20 a.m. Six (6) cups were stored in the refrigerator. Two (2) cups were labeled with names and dates (one dated the day of the visit and one dated 4/16/26). The remaining four (4) cups were unlabeled. The refrigerator temperature was observed at 45°F. Diaper creams were monitored. Two (2) permission forms were expired, and no permission forms were on file for two (2) additional diaper creams. One (1) emergency medication (inhaler) was stored in the classroom. While storage was adequate, no action plan was on file. Medication authorization form contained name of medication, child’s name, child’s date of birth, dosage/route, reason for medication and a physician’s signature. Time was blank, and the frequency was noted as every four (4) hours. Significant information and instruction were also blank. No parent signature was found on the form. The medication record indicated that it was administered to the child on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. The safe sleep policy, safe sleep poster, staff/child ratio form, lesson plan, and two (2) feeding plans and EMC were posted. Space #2: This space was closed due to staff shortage but remained monitored. No diaper creams were present, and no hazardous materials were accessible to children. Space #3: Seventeen (17) children, ages two (2) to five (5), were present with two (2) staff members. During the observation, one (1) child was in Space #2 with a therapist. Children were actively engaged in free play. One (1) child built a tower with soft blocks and then kicked a block toward it. Other children played with puzzles, housekeeping materials, and manipulatives. Three (3) children were observed in a quiet cube and then began tumbling on a child-sized chair/bed in the library area. One (1) staff member called two (2) of the children over and calmly instructed them to settle down. The children returned to the library area and resumed tumbling shortly thereafter. One (1) staff member was positioned in the housekeeping area, while the other was positioned near a table by the entrance door. The group later transitioned outdoors. Children were observed riding bikes, digging in a planter, and climbing on tunnels. No medications were maintained in space #3. Staff members in both space #1 and #3 were able to hear or see the children at all times during observation. Interaction among staff members and children were adequate. Breakfast today was bagels with cream cheese, pears and milk. On the menu, English muffin, eggs, peanut butter and milk were listed. Eight (8) staff members’ files were monitored partially for criminal background letters and special training, and two (2) new staff files were monitored in full. All existing staff members had valid CPR/First Aid training, CBC letter and ITS/SIDS training certificates on file. The following information was reviewed for the new staff members: M. Smith DOE: 2/6/26 Position: LT Education: AAS in ECE EPR review: 3/18/26 EMC review2/6/26 Health and Safety Training: Some training certificates on file are dated March 2021. Only training completed within twelve months prior to the first day of employment is considered valid. The Medication in Child Care training completed on 5/16/25 meets this requirement and is valid. All other training, excluding CPR/First Aid, must be retaken. ITS/SIDS: completed on 5/16/26, expires on 5/16/29 Orientation: The following dates were listed for 2-wk orientation Recognizing and Responding to Suspicions of Child Maltreatment …and G.S. 7B-301: 12/13/23 Information regarding prevention of shaken baby syndrome and abusive head trauma, and child maltreatment: 2/12/21 Prevention and Control of Infectious Diseases … including Immunizations: 2/28/21 Adequate supervision of children… .1801 – not dated Orientation topics may not be completed through Health and Safety Training and must be reviewed separately. These topics are not intended to be general knowledge but must include specific information related to your program. For example, for Recognizing and Responding to Suspicions of Child Maltreatment and G.S. 7B-301, staff should review program-specific procedures such as the contact phone number or email for the local Department of Social Services and appropriate actions to take—or not take—when abuse or neglect is suspected. For Prevention and Control of Infectious Diseases, staff must review the specific procedures followed by the program, including the location of the bloodborne pathogen kit and the proper methods for handling and disposing of contaminated materials. Additionally, all topics must be reviewed and the name of the provider must also be documented. 6-week orientation: 2/9/26 but the name of the provider was not documented. No hours were recorded for 2-week or 6-week orientation. application: 1/21/26 CBC: dated 8/19/21, expires on 8/19/26 OP/PP: 2/6/26 Review of Shaken Baby policy: 2/6/26 TB: 1/21/26 Medical: 1/21/26 HQ: 1/21/26 EI: 2/3/26 K. Haney: DOE: 3/16/26 Position: T CBC: issued on 5/12/23, expires on 5/12/28 EPR review: 3/18/26 EMC review: 3/18/26 Shaken Baby policy review: 3/5/26 OP/PP: 3/15/26 2-week orientation: 3/18/26 – information regarding … child maltreatment and prevention … including immunizations did not have dates, training hours or training provider. All topics were missing training provider. 6-week orientation: incomplete Application: 3/12/26 HQ: 3/15/26 EI: 3/15/26 Medical: 3/15/26 but missing address and phone number. TB: missing health care professional’s signature and date. Ms. Mashburn stated that she misunderstood about the TB requirements. She thought that no signature was required from the physician if the new employee answered no to all questions. I explained that TB skin test is not required with all questions being answered no. However, a licensed health care professional must verify the answers and sign off. Ms. Mashburn stated that she accepted the staff member’s medical statement without checking the details and was not aware of any missing information on the form. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. One (1) child who was present in space #1 was not signed in with arrival time. 10A NCAC 09 .0302(d)(4) 319 Staff/child ratios applicable to a classroom, were not posted in each classroom. Staff/child ratio was not posted in space #3. .0713(a)(10), (c) & (f)(3); .2818(e) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. Today, bagel with cream cheese, sliced pears and milk were served for breakfast while English muffin, eggs, peanut butter and milk were listed on the menu. Substituted items were not written on the menu prior to serving children. 10A NCAC 09 .0901(b) 536 Formula and other beverages which require refrigeration were not identified for each child or properly refrigerated. Out of six (6) beverage containers in the refrigerator in space #1, two (2) of them were labeled with children's names and dates - one (1) dated 4/21/26 and the other dated 4/16/26. 15A NCAC 18A .2804(d) 807 A safe indoor and outdoor environment was not provided for the children. Baby food Sweet Potato with expiration date of November 20, 2025, was served to an infant in space #1. There were multiple packets of Gerber baby food products that were expired stored in the cabinet by the entrance door in space #1. 10A NCAC 09 .0601(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 Clorox Clean-up Multi-Surface Cleaner + Bleach was stored on the top shelf above the sink in space #1. .2820(b) 842 A drug or medication was administered without written authorization and/or instructions from a child's parent or authorized health professional. Medication authorization form contained physician's signature but not the parent's signature for Albuterol in space #1. The medication record indicated that it was administered on 10/7/25 at 11:45 am and 10/8/25 at 11:15 am. 10A NCAC 09 .0803(1)(a & b) 847 Parent's medication authorization did not include required information. Two (2) medications did not have parent authorization form on file - 1. A+D Prevent and Heat 2. Maty's Baby Multi-purpose ointment. Both medications were maintained in space #1. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The authorization form for two (2) diaper creams expired but the creams were not discarded or returned home. Destin diaper cream for a child in space #1 expired on 4/8/26, and Zinc Oxide Ointment for a child in space #1 expired on 3/17/26. .0803(12) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/or the medical report was older than 12 months. The medical statement for a staff member with an employment date of 3/16/26 did not have a correct health care professional's name and was missing contact information. The name of health care professional was written "Mayhec" and the signature looked like a scribble, and the address and phone number was not filled out. 10A NCAC 09 .0701(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 form for a staff members with an employment date of 3/16/26 did not have a health professional's signature, printed name, location and date. Additionally, consent signature for accurate information was also not signed and dated. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. The orientation form for a staff member hired on 2/6/26 did not have any hours spent on each topic documented. The provider section was also undocumented. .1101(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. A staff member who was hired on 2/6/26 did not review the following topics during first two (2) weeks of employment: Recognizing, responding to, and reporting child abuse, neglect, or maltreatment pursuant to G.S.110-105.4 and G.S. 7B-301. Adequate supervision of children in accordance with 10A NCAC 09 .1801. Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. A staff member who was hired on 3/16/26 did not review the following topics: Information regarding prevention of shaken baby syndrome and abusive head trauma and child maltreatment. prevention and control of infectious disease, including immunizations. .1101(a)(b) 1756 Enhanced staff/child ratios and group sizes were not met. Between 9:08 am and 9:20 am, one (1) staff member was left with six (6) children aged 0-1 at multiple occasions while the other staff member left space #1 to answer the door. The program follows enhanced staff/child ratios. 10A NCAC 09 .2818 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. Action plan for Albuterol Sulfate in space #1 was not on file. .0801(b) 1848 The child care environment was not smoke and/or tobacco free. When a parent/guardian picked up a child, he/she had a purple vape device on his/her hands while standing outside of entrance door. .0604(h) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. The medication authorization form for Albuterol did not contain parent signature and date. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time must be recorded as children arrive/depart. To comply, arrival time for one (1) child in space #1 had to be recorded as he/she arrived. Ms. Mashburn recorded the time around 9:30 am. Even though arrival and departure time needs to be recorded as children arrive/depart, this item is considered corrected during visit. Please continue to record each child’s arrival and departure time accurately. 319: Staff/child ratio Staff/child ratio form must be posted in each space used by children. To comply, post staff/child ratio form in space #3 and check appropriate box. The lead teacher in space #3 receive a copy of the staff/child ratio form and posted in the classroom during the visit. This item was marked corrected during visit. 528: food substitution Food substitution must be recorded on the menu prior to serving children. To comply, you must record bagel with cream cheese, pears and milk on today’s menu. Ms. Mashburn recorded correct items for breakfast on the menu. Therefore, this item was marked corrected during visit. 536: bottled beverages Bottled beverages, including sippy cups, bottles and other drinking/eating containers must be labeled with child’s name and date. To comply, each bottle and food container shall be identified for each child. Staff member wrote today’s date and names of children on the bottle upon my request. Therefore, this item was corrected during visit. 807: safe environment Safe environment must be maintained at all times. No expired food or beverages shall be served to children. To comply, go through the storage for food supplies and discard all expired items. Ms. Mashburn and the staff members reviewed the dates of all baby food in the cabinet and discarded the expired items. Therefore, this item was marked corrected during visit. The staff member stated that the sweet potato was provided by the child's parent the morning of 4/21/26 (today). There were multiple packets of Gerber baby food products in the cabinet that were expired. It is staff members' responsibilities to ensure that food is not spoiled before serving children. 840: hazardous products Any potentially hazardous items must be stored in a locked storage. To comply, a bottle of Clorox Clean-Up Multi-Surface Cleaner with Bleach must be moved to a locked storage. The Clorox spray was moved from the classroom. This item was corrected during the visit. 847: medication authorization form No medications including over-the-counter and prescription products can be administered without parent authorization. To comply, parents must fill out authorization forms for A+D prevent and heat ointment and Maty’s Baby Multi-purpose ointment All sections on the form shall be filled out. Ms. Mashburn plans to get the authorization forms signed. 842: administration of medication No medications, prescription or over-the-counter products, can be administered to a child without parental authorization. To comply, medication authorization for Albuterol must be obtained before the medication is administered. Ms. Mashburn will request the authorization form from the parent. 849: Left over medications Within seventy-two (72) hours of authorization form being expired, the medication must be returned home or discarded. To comply, Destin diaper cream and Zinc Oxide Ointment must be returned home or discarded. 1032: Medical statement The medical statement must be completed in its entirety. Medical statement must be obtained on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact MAHEC and receive adequate signature, name of health care professional, address and phone number. 1033: TB TB screening must be complete in its entirety including health care professional’s signature, and other information. TB screening must be completed on or prior to first day of employment. To comply, a staff member employed on 3/16/26 shall contact the physician who reviewed the form and ask for a signature and other required information. 1045: 6-week orientation Minimum of sixteen (16) hours of orientation is required within the first six (6) weeks of orientation. To verify that you meet this requirement, you must complete the orientation form in its entirety. You must complete hours for each topic and provider for M. Smith. Ms. Mashburn will review the form and fill it out. 1067: 2-week orientation Minimum of six (6) hours of orientation is required for the first two (2) weeks of orientation and all the topics must be reviewed. To comply, you must review all topics listed under two-week orientation and record time spent on each topic and provider name for M. Smith. Since you recorded the date of Health and Safety training instead of review of facility related topics, you must start over. As for K. Haney, you must review information related to prevention of shaken baby syndrome, abusive head trauma and child maltreatment and prevention of infectious diseases, including immunizations with the staff member and record the hours as well as training provider. Ms. Mashburn plans to review the topics and record required information. 1756: enhanced staff/child ratios Enhanced staff/child ratios must be met at all times. Each staff member shall be aware of required staff/child ratio and ask for help as needed. If one (1) staff member shall need to get to the door, some children shall be taken with the staff member to maintain the appropriate staff/child ratios. This violation required a follow-up visit. 1834: Action plan Action plan must accompany application when a child has chronic medication conditions. To comply, action plan for Albuterol Sulfate must be completed and maintain on file. Action plans can be completed by a licensed physician or the parent of the child. Action plan is valid for up to twelve (12) months. Ms. Mashburn will request the parent to obtain action plan for a child with albuterol. 1848: Tobacco products 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (h) Children shall be in a smoke free and tobacco free environment. Smoking and the use of any product containing, made or derived from tobacco, including e-cigarettes, cigars, little cigars, smokeless tobacco, and hookah, shall not be permitted on the premises of the child care center, in vehicles used to transport children, or during any off premise activities. All smoking materials shall be kept in locked storage. For child care centers in an occupied residence that are licensed for 3 to 12 children when any preschool-age children are in care, or for 3 to 15 children when only school-age children are in care, the premises shall be smoke free and tobacco free during operating hours. Per rule listed above, child care center premises must be tobacco free. To comply, I suggest sharing the details of your tobacco restriction policy with all parents again to ensure that parents are mindful of the rule. 1882: Authorization form Authorization form must contain the following: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. To comply, medication authorization form for Albuterol must include all the information listed above. Ms. Mashburn stated that she would make sure that the listed information are included on the authorization form. Achieving Compliance: A follow-up visit will be conducted to verify compliance of enhanced staff/child ratio requirements per 10A NCAC .2818. Additionally, sixteen (16) or more violations cited during today’s visit required a follow-up visit. Both sixteen (16) or more violations and a violation of staff/child ratio may warrant administrative action. 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 5/5/26. 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: Compliance history: After today’s visit, your compliance history is expected to be seventy-four (74) percent. You must maintain minimum of seventy-five (75) percent. Programs with compliance rate lower than seventy-five (75) percent may be considered for administrative action. CPR/First Aid training and Recognizing and Responding to Suspicions of Child Maltreatment training must be completed by M. Smith on or prior to 5/7/26. Water lead testing: You are due to complete water lead testing again on or before 8/29/26. Playground fall zones: Ms. Mashburn stated that the program was approved for playground renovation, which would occur within 3-4 weeks. She plans to remove any equipment with critical height of eighteen (18) inches or higher. I reminder her of “intended use” of each equipment – tunnels and chairs are not meant for climbing. Staff shall be mindful of what equipment is intended for and guide children to use it accordingly. Otherwise, it is supervision issue, and the equipment shall have appropriate fall zones. Due to upcoming renovation, no violations regarding playground was cited during today’s visit. Orientation: Most of your staff member is missing information on their orientation sheet. Please review them and complete the forms. K. Haney has not completed 6-week orientation until all required topics were reviewed. 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 .0601 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0302 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0508 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0510e · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0601 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0801 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0902 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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

GS 110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: 0226-342L Visit Date: 3/5/2026 Number Present: 24 Completed Date: 3/5/2026 Age: From 0 To 5 Total Minutes: 479 Time In: 09:06 AM Time Out: 05:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s visit is to investigate allegations of child care requirements. A computerized generated report of today’s visit was completed and signed by Kaoru Eddins, Child Care Consultant. Katherine Mashburn was present on-site until approximately 2:30 pm. Due to Ms. Mashburn leaving the program prior to completing this visit, a signature was not obtained. A copy of the visit summary was emailed to Ms. Mashburn. Ms. Mashburn assisted me today. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty (80) percent as of today prior to this visit. The facility operates with a four-star license issued 4/6/18. The Special Services/Restrictions include daytime care, meets enhanced ratios and space. The complaint was received by the Division of Child Development and Early Education on 2/27/26 and sent to me on 3/3/26. In addition to addressing the allegations, staff/child ratio, group size, supervision, use of licensed space, space capacity, permit restrictions, license posted, safe environment and program records were monitored. Allegations within the report included the following: *Required nutrition requirements were not met. *Appropriate staff/child ratios were not maintained. *Staff members did not adequately supervise children. *Infection and contagious disease protocol was not followed. *Emergency Medical Care procedures were not followed. *Approved space was not used. *Adequate learning environment was not provided to children. * Floor and floor coverings were not kept clean. * In appropriate discipline was used. * Safe environment was not provided. The information obtained by the Division include the following details. The allegation occurred on undetermined date and time: • Cereal and milk were served for breakfast without a third component. • A total of twelve (12) students, aged three-to-five or two-to-five years of age, were cared for by one (1) staff member. • A staff member left wailing child unattended for approximately twenty (20) minutes. • A child who arrived late stated that he/she had been throwing up and was allowed to stay. • A child had multiple seizures, and the staff member did not follow Emergency Medical Care procedure and called 911. • A storage space was used for twelve (12) students. • Very few toys were available for children. • Rugs were dirty. • A staff placed a child between his/her feet and restrained the child with his/her feet and legs for approximately five (5) to seven (7) minutes. • A staff member was impaired under influence of substance. Upon arrival, I announced my presence and the purpose of the visit. A walkthrough of the entire center was conducted to include three (3) classrooms in operation today. Ms. Mashburn partially accompanied me during the walkthrough. In space #1, a total of five (5) children, including infants and one-year-olds, were present with two (2) staff members. Two (2) infants were being held by staff members while the other children, all one (1) year of age, played with materials. One (1) child, age one (1) year with a birth date of 3/15/24, was lying on an infant bouncer. A large table was placed in the middle of the room and occupied most of the open space. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. The lesson plan was posted and dated 2/16–2/20/26. Additional child, age one (1) year, arrived at 10:11 a.m. One (1) child, one (1) year of age, was observed tearing plastic off a picture cube with his/her teeth. The child continued to tear the plastic several times. The child spit out some of the plastic pieces and swallowed some. A staff member in the same area verbally corrected the child, stating, “You cannot bite that” and “Quit biting because you will choke on it.” The cube was taken from the child after the child chewed off multiple small pieces of plastic. The picture cube was returned to the shelf after the incident. In space #2, a group of five (5) children, one-to-two years of age, were present with one (1) staff member. The group of children played on the infant/toddler playground with pretend dishes, sat on the bench and walked around. In the classroom, lesson plan was posted and dated 1/5/26 – 1/9/26. In space #3, ten (10) children, two-to-four years old, were present with two (2) staff members. one (1) child arrived at 9:18 am and another at 9:22 am. Both children washed their hands upon arrival. Lesson plan was posted and dated 1/2/26 – 1/16/26. Six (6) children were observed in the housekeeping area, and three (3) of them were wearing dress-up clothes and hats. One (1) child sat at the table and played with puzzles and a magnetic wand. A staff member stood by the table and supervised and interacted with the children in the housekeeping area and at the table. The other staff member maintained a close distance with a child who roamed around the classroom. When two (2) children started running/tumbling on the floor and in the book/quiet area, the staff member near the housekeeping area verbally corrected the child to stay safe. He/she said “That’s not safe. Reading area is for reading”. One (1) of the children followed the staff’s instruction and started reading while the other child continued to tumble and run in the classroom. The staff member who verbally corrected the behaviors approached the child who continue to tumble and guided the child to the table to play with other materials. The children from space #3 were observed on the playground. Children rode tricycles, used see-saw, climbed on the metal car structures and tunnel structure. When children climbed on the metal cars and tunnels, staff members verbally corrected them from distance. After multiple verbal corrections, staff members walked to the children and instructed them to use the equipment appropriately by sitting on the seats of the metal car structure and getting down from the tunnel structure. Staff members were observed to instruct children not to crash the tricycles. Each time a child attempted to stand on the back of a tricycle while another child was riding it, a staff member verbally instructed the child to get down. One (1) child was physically removed from the tricycle after standing on it multiple times. On two (2) separate occasions during the observation, one (1) child attempted to stand on the back of the tricycle. Two (2) children turned around and told the child, “No.” The child who was told “no” then hit both children. One (1) staff member approached the child who hit the other children, picked him/her up, and held him/her for a period of time. The child was not struggling and appeared comfortable being held. Neither the staff member nor the child appeared upset or struggling. Per interview with the staff member who held the child following the hitting incident, the staff member stated that gently holding the child was suggested by a therapist when the child displayed any challenging behaviors. The staff member also stated that the child continues to display challenging behaviors. One (1) child was taken into the classroom by a therapist during the observation. Shortly after the therapist left the center, a child was heard in space #3. When looking in the direction of space #3, one (1) child, four (4) years of age, was observed standing alone by the classroom door. I walked to space #3. As I entered the classroom, one (1) staff member was observed running toward the far corner of the L-shaped classroom, approaching the point where the room turned, and the other staff member stood at the door on the playground side. One (1) staff member stated that the therapist did not close the door tightly. Based on the estimated time between when the therapist left the center and when the child was observed standing by the classroom door, the staff member followed immediately after the child entered the classroom. The time elapsed between the child entering the classroom and the staff member entering was estimated to be less than thirty (30) seconds. Ms. Mashburn also stated that the child was unable to open the door independently; therefore, it was likely that the door had not been closed tightly by the therapist. The same child had been observed on the playground earlier repeatedly attempting to open door handles; however, the child was unable to open the doors. Chicken tenders, mixed vegetables, peach slices and milk were served for lunch, and the items were accurately listed on the menu. An Environmental Health Specialist briefly accompanied me on this visit. He monitored a floor covering, soft furniture and stuffed animals around the cozy cube in space #3. He instructed Ms. Mashburn to remove the rub, the cover of soft chair and stuffed animals and wash them. Rest time was monitored. Two (2) children in space #3 were observed using weighted blankets. Staff members rotated to take lunch breaks during rest time. Ms. Mashburn assisted in space #1 during this period. One (1) child, who was school-age/five (5) years of age, was dropped off at the center by a school-bus. The child was on the playground with a therapist. The child’s mother was one (1) of the staff members. I was unable to review the child’s record, but the staff member/mother verified that the child had a file. The following allegations were investigated as follows: Nutrition requirements: All staff members were interviewed regarding their nutrition practice. All staff member stated that they had never seen children being served with milk and cereal without fruits or the 3rd component. Breakfast was not observed during today’s visit. Lunch was observed and met all nutrition requirements. The breakfast menu for 2/24/26 – 2/27/26 was reviewed. The menu listed the following items: 2/24/26: English muffin, egg, cheese, potatoes, and milk 2/25/26: Cheerios, applesauce, and milk 2/26/26: Frosted Mini-Wheats, blueberries, and milk 2/27/26: English muffin, strawberries, ham, cheese, and milk Due to lack of evidence that only two (2) components were served for breakfast, the allegation of nutrition violation was unsubstantiated. Staff/child ratios: All staff members were interviewed, and they stated that no staff members had been out of ratios. I reviewed the program records including children’s attendance record and staff time sheets. Based on the information obtained by the Division, I reviewed the records of 2/20/26, 2/25/26, 2/26/26 and 2/27/26. 2/20/26: A total of twenty-one (21) children were in attendance with six (6) teaching staff members present. Arrival times for three (3) children were not recorded; therefore, accurate staff-to-child ratios could not be determined. Staff arrival times were as follows: Staff #1 at 6:50 a.m., Staff #2 at 7:19 a.m., Staff #3 at 7:44 a.m., Staff #4 at 8:01 a.m., Staff #5 at 8:08 a.m., and Staff #6 at 8:29 a.m. At least six (6) children were present between 7:00 a.m. and 7:59 a.m., eight (8) children arrived between 8:00 a.m. and 8:59 a.m., and three (3) children arrived between 9:00 a.m. and 10:00 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:19 a.m.; however, three (3) children’s arrival times were not documented. 2/25/26: A total of twenty-two (22) children were in attendance with six (6) teaching staff members present. Arrival times were recorded for all children. From 7:00 a.m. to 7:59 a.m., nine (9) children arrived; from 8:00 a.m. to 8:59 a.m., eleven (11) children arrived; one (1) child arrived between 9:00 a.m. and 9:59 a.m.; and one (1) child arrived between 10:00 a.m. and 11:00 a.m. Staff arrival times were as follows: Staff #1 at 6:47 a.m., Staff #2 at 7:14 a.m., Staff #3 at 8:03 a.m., Staff #4 at 8:05 a.m., Staff #5 at 8:12 a.m., and Staff #6 at 8:12 a.m. One (1) child, four (4) years of age, was present between 7:00 a.m. and 7:14 a.m., and eight (8) children arrived between 7:14 a.m. and 7:59 a.m. Between 7:14 am – 7:59 pm, there were one (1) infant, two (2) children who were one (1) year of age, one (1) child who was two (2), three (3) children, who were three (3) and one (1) child who was four (4). This was a first hour of care, and two (2) staff member were present to meet 1:5 staff/child ratio for infants with maximum group size of ten (10). After 8:00 am, four (4) additional staff members arrived and two (2) staff members were present in each classroom. 2/26/26: A total of twenty-four (24) children were present with five (5) staff members. From 7:00 a.m. to 7:14 a.m., one (1) child, four (4) years of age, was present with one (1) staff member who arrived at 6:41 a.m. Eight (8) children arrived between 7:15 a.m. and 7:59 a.m., ten (10) children arrived between 8:00 a.m. and 8:59 a.m., and five (5) children arrived between 9:00 a.m. and 10:00 a.m. Staff arrival times were as follows: Staff #1 at 6:41 a.m., Staff #2 at 7:14 a.m., Staff #3 at 7:53 a.m., Staff #4 at 8:00 a.m., and Staff #5 at 8:21 a.m. Between 7:00 am – 8:00 am, there were one (1) child, who was four (4), three (3) children who were three (3), three (3) children who were two (2) and two (2) children who were one (1) year old. During this time, one (1) staff member was present between 7:00 am – 7:14 am, two (2) staff members were present between 7:14 am – 7:53 am and three (3) staff members were present between 7:53 am – 8:00 am. Between 8:00 am- 9:00 am, three (3) children who were three (3), two (2) children who were two (2), three (3) children who were one (1) and two (2) children who were infants arrived, and a total of at least four (4) staff members were present. One (1) staff member who was assigned to #1 was clocked in at 7:14 am, one (1) staff member assigned to space #2 clocked in at 6:41 and one (1) staff member assigned to #3 clocked in at 8:00 am. Therefore, staff/child ratios in each classroom was possible to maintain though which classroom each child was assigned to during the time was unknown. 2/27/26: No children’s attendance records were provided. Ms. Mashburn was unable to locate the records of children’s arrival and departure times and did not recall whether the school was open or closed. Based on four (4) staff members being on the clock, it was determined that the school was in operation. From diaper record, I was able to determine that five (5) children attended space #1 that day. Staff #1 arrived at 7:16 am, staff #2 arrived at 8:04 am, staff #3 arrived at 8:17 am and staff #4 arrived at 9:01 am. Due to lack of children’s attendance record – no other documentation that verified children’s attendance, I was unable to determine if staff/child ratios were maintained. Due to lack of evidence that staff/child ratios were not maintained, allegation of staff/child ratios were unsubstantiated. Supervision: All staff members were interviewed for supervision requirements. All staff members stated that they had not witnessed any children being left unattended. I observed a child who had a seizure disorder. The child was in space #3. The child mostly walked around the classroom rather than engaged in free play with materials. The child seemed non-verbal and made vocal sounds, including ‘ah,’ woo,’ and ‘oh throughout the day. The child frequently hits himself/herself in the face without being upset. I observed the child in the classroom and outside making verbal sounds, walked around and hit himself/herself in the face. The child did not cry or seemed upset. On the playground, the child remained near the door and attempted to open the doors to classroom #3, #2 and #1. Staff members picked the child up a few times and talked to him/her, but the child was left alone most of the time. Staff members were aware where the child was. Staff members walked around and addressed different children throughout the day including the child with special needs. Although the child, who was non-verbal, entered the building independently, staff members were aware of the child’s location on the playground. When the therapist returned the child to the playground, neither staff member was in close proximity to the door. The child independently opened the door and briefly entered the classroom alone. Both staff members responded immediately and attended to the child. Based on the observation and staff statements, the allegation of inadequate supervision was unsubstantiated. Additionally, no supervision violation was cited during today’s visit. Staff members were actively moving about the classroom and on the playground and interacting with children, primarily providing guidance and correcting undesired behaviors. Space #3 included multiple children with high supervision needs. Two (2) staff members were positioned opposite ends in the classroom and across the large playground and actively supervised children while addressing behavioral concerns. Infectious and contagious disease: All staff members were interviewed and stated that no children with illnesses were allowed to attend the school. Per Ms. Mashburn, the program’s records follow DCDEE guidelines for the exclusion of children. Children with fever, vomiting, diarrhea, or other communicable or contagious illnesses were excluded from attendance. Two (2) children, one (1) in space #3 and one (1) in space #1 had clear nasal discharges. However, no children appeared to be ill during today’s visit. Due to lack of evidence, allegation of violation of infectious and contagious disease was unsubstantiated. Emergency Medical Care Plan: The allegation was that staff members did not follow the procedures for seizures. I observed a child who had a seizure disorder. The child did not have noticeable “seizure” during observation as he/she was walking around and conscious during my observation. The child’s guardian (foster parent) was one (1) of the staff members. Per interview with the guardian, the child has many seizures throughout the day. Some of them were absent seizures, drop seizures and jolt seizures. It is rare that the child falls on the ground and seizes. Most of the time, the child stars at one (1) point or looks disoriented or moves abruptly. The guardian stated that self-hitting action often triggers jolt-seizures. The child takes daily medications typically prior to attending school. No medications were maintained in the classroom, but the guardian maintained them in his/her bag. No staff members administer medications to this child, and the child does not attend when the guardian/staff member does not work. Lunch – chicken fingers were cut up to small pieces as it was directed by doctor’s note. No action plan was on file for this child. Due to guardian on-site and responsible for care of this child, allegation for not following Emergency Medical Care Plan, was unsubstantiated. Use of unapproved space: All staff members were interviewed and stated that only approved spaces were used to care for children. There was a shed off property. No children were observed in the shed during today’s visit. Additionally, children were cared for in space #1-#3, which are all approved space. Based on the observation, allegations of use of unapproved space were unsubstantiated. Adequate Learning Environment: In space #3, following materials were observed: • Wooden cubes with letters and pictures, • Dress up clothes • Pretend food, pots, pants and other utensils, • Assorted puzzles, • Baby dolls and accessories • Pretend animals, sea animals • Pretend people • School vehicle toys • Natural wood pieces • Pick-a-boo blocks • Bolts • Soft blocks • Small blocks • Soft things – pillows and stuffed animals • Instruments, books • Magnetic tiles • Ice cream and cones • Keys and locks and many other manipulative toys In space #2, following materials were observed: • A container of stacking stones • A barn house • At least fifteen (15) pretend vehicles\ • A container of pretend fall leaves • A drum and five drawers of instruments, such as tumbling, castanet, and bells • A tunnel • Pretend kitchen furniture • Pretend pots and other utensils • Pretend food, pretend dish rack, blender, vacuum cleaner, • Pretend phone, baby clothes, bottles, dols • Dress up clothes and accessories • Many stuffed animals Space #1 offers very small play space with three (3) cribs and one (1) full-child-size table, a changing table present. The children had access to soft materials, such as rattles, soft blocks, pretend animals, soft books, push toys, picture cubes, rockers, etc. Space #1 is approved for nine (9) children, space #2 is for nine (9) children and space #3 is for twenty-one (21) children. Ms. Mashburn and I discussed the importance of open space for infants and young toddlers for space #1. Based on the observation, allegation of inadequate learning environment was unsubstantiated. Sanitation: Based on the observation and notes from the Environmental Health Specialist, it was determined that A rug in space #3, stuffed animals and soft chair needed to be washed. Therefore, allegation of sanitation violation was substantiated. Inappropriate discipline: During today’s visit, staff members frequently provided verbal corrections to children from a distance. The tone of voice was calm and not harsh or yelling. After multiple verbal corrections, staff members physically approached the children to redirect them or, when necessary, picked them up and removed them from the area. One (1) child, who persistently attempted to stand on the back of a tricycle on the playground, was physically removed by staff after ignoring verbal corrections. When the child hit two (2) other children, one (1) staff member picked the child up and held him/her for approximately fifteen (15) minutes. The child was not restrained but was gently held. No harsh exchanges were observed, and both the staff member and the child remained calm. Staff members were interviewed and stated that they had not witnessed any children being restrained in the form of discipline. Based on the observation and interview, allegation of inappropriate discipline was unsubstantiated. Safe environment: Staff members were interviewed and stated that they had never been under the influence of any substances while working and had not observed any other staff members working under the influence. During today’s observation, no substances were detected by smell, and no staff member exhibited signs of impairment, such as unsteady movements. Due to lack of evidence, the allegation of violation of safe environment was unsubstantiated. The following violations were documented during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Three (3) children did not have arrival time documented for 2/20/26. Two (2) children did not have departure time documented for 2/24/26. Attendance record with arrival and departure time was not found for 2/27/26. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. The lesson plan was posted and dated 2/16–2/20/26 in space #1. Lesson plan was posted and dated 1/5/26 – 1/9/26 in space #2. Lesson plan was posted and dated 1/2/26 – 1/16/26 in space #3. GS 110-91(12); .0508(a) 451 For children under three years of age, an open area that allows freedom of movement was not available, both indoors or outdoors. A large table was placed in the middle of the room and occupied most of the open space in space #1 with infants and children who were one (1) year of age. Due to the placement of the table, another child climbed over the child in the infant bouncer to reach the other side of the room. Additionally, when one (1) child pushed a toy cart, the child was only able to move the cart approximately 1.5 feet due to the limited space available. .0510(e)(4) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Feeding plan for one (1) child with birth date of 7/11/25 was not signed by the parent. .0902(a) 603 All floors and floor coverings were not constructed of nonabsorbent material and/or were not kept clean and in good repair. The circular rug in space #3 was stained, and debris was observed on the rug. 15A NCAC 18A .2824(a)&(b) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. A pretend asparagus in space #3 was not removed after a child put it in the mouth. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. Weighted blankets were used for two (2) children - aged four (4) and two (2) years old during nap time during today's visit. additionally, one (1) who was twenty-three (23) month of age, were observed to use infant bouncer in space #1. 10A NCAC 09 .0601(a) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. One (1) child, who was four (4) years of age, in space #1 with a seizure disorder, did not have action plan on file. .0801(b) 1864 Outdoor play equipment was not age and developmentally appropriate. HQBB tricycles with critical height of approximately fifteen (15) inches were offered to children as young as two (2) years old. Based on the information obtained on the website, yellow HQBB tricycles were for children ages three (3) to eight (8) years of age. .0605(a) Technical assistance was provided as follows: 125: record of arrival and departure Daily records of arrival and departure times for children at the center must be maintained and available for review. To comply, please determine the arrival and departure time of children who are missing the record on 2/20/26, 2/24/26 and 2/27/26 and document them at best of your ability. Due to Ms. Mashburn leaving at 2:30 pm, this violation was not discussed. In your compliance letter, please state how you met the compliance. 428: activity plans Activity plans must be current and posted for each group of children. To comply, current lesson plans for space #2 and #3 must be posted. Current activity plan was posted in space #1 during the visit. Ms. Mashburn stated that she would discuss this requirement with staff members and post the current activity plans. Refer to 10A NCAC 09 .0508(a). 451: activity area for infants and toddlers An open area that allows freedom of movement must be available both indoors and outdoors. To comply, I suggest removing the child’s table from space #1 or replace it with much smaller table, preferably moving away from the free play area. Ms. Mashburn plans to replace the table with smaller one. Refer to 10A NCAC 09 .0510e(4) 541: feeding plan The written feeding plans must be signed by the parents. This is a nutrition requirement, but it is not substantiation of allegation. To comply, a feeding plan for one (1) children with birth date of 7/11/25 must be signed by the parent. Ms. Mashburn stated that she would request the parents to sign the feeding plans. In your compliance letter, please verify that both feeding plans were signed by the parent. Refer to 10A NCAC 09 .0902(a). 603: Floors and Floor coverings Floor and floor coverings must be kept clean and in good repair. This was substantiation of an allegation. To comply, a circle rug in space #3 needs to be washed. Rugs in space #2 and #3 need to be vacuumed. Ms. Kathy stated that she was planning to take the circle rug home and wash it. She would bring a vacuum cleaner and vacuum the rugs in space #2 and #1. Note: Staff members sweep the rugs daily. Refer to 15A NCAC 18A .2824(a & b). 616: mouthed toys Mouth-contact toys must be cleaned and sanitized daily. To comply, remove the mouthed toys and sanitize them at the end of the day. The pretend asparagus in space #3 must be removed and sanitized. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility at 2:30 pm. 807: Safe environment Safe environment must be provided for children. This violation was cited due to use of weighted blanket. This is not substantiation of allegation of safe environment. The use of weighted blankets must be included in the child’s IEP. One (1) child had IEP, but the use of weighted blanket was not included in the IEP, per statement from the child’s guardian. The other child did not have IEP. However, staff members stated that the children’s therapists suggested using weighted blankets. To comply, stop using weighted blankets immediately. To use weighted blankets, the use must be included in the children’s IEP. I was unable to discuss this violation with Ms. Mashburn as she had to leave the facility around 2:30 pm. In space #1, a child, one (1) year of age, were observed to be laying on an infant bouncer. This was not age-appropriate and a risk for injuries. To comply, staff members must be aware of developmentally and age-appropriate use of materials and supervise children for appropriate use of materials. Ms. Mashburn plans to review the requirements with staff members. In your compliance letter, please address two (2) separate violations – use of weighted blanket and use of infant bouncer – and state how you met the compliance. Refer to 10A NCAC 09 .0601(a). 1834: Seizure Action Plan An action plan for chronic medical conditions must be attached to the enrollment application. To comply, the guardian or a child’s physician must fill out a seizure Action Plan in detail. Ms. Mashburn stated that she would ask the child’s guardian to fill out the seizure action plan. Refer to 10A NCAC 09 .0801(b). 1864: Developmentally/age-appropriate equipment Outdoor equipment must be age and developmentally appropriate. Per information on HQBB tricycles, they are for children ages three (3) to eight (8). To comply, you must offer alternate equipment for children two (2) years of age. Ms. Mashburn stated that she would remove the tricycles from the playground. In your compliance letter, please state how you met the compliance. Achieving Compliance: The violations documented above must be corrected immediately. Please submit a compliance letter or send me a compliance letter 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# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 3/19/26. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) 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: Healthy Social Behaviors: I recommend you contact The Healthy Social Behaviors Project (HSB) and consult how to address challenging behaviors in a long term. Rather than only addressing negative behaviors, recognizing positive behaviors is important to teach children how to gain staff attention. Addressing challenging behaviors must be simple and short and natural consequences to limit their choices can be used if developmentally appropriate. Addressing challenging behaviors from a distance often does not work as children tend to ignore anyone talking from far away. Staff members shall walk to the child and address each behavior. You can reach HSB at 1-888-600-1685 option 1. You can also access coaching and training at HSB@ChildCareResourcesInc.org Fall zone: During today’s visit, many children were observed climbing on the handle of a metal vehicle and on top of a tunnel structure. Both the vehicle and the tunnel were portable equipment. Each time, staff members instructed the children to use the equipment appropriately. Staff members must closely supervise the use of the equipment and make sure that children are using it appropriately as intended by manufacturers. If children continue to climb on the equipment, fall zone with appropriate loose surfacing is strongly recommended. As the loose surfacing around the see-saw washes out, the critical fall height of the equipment changes. If the critical height of a permanent structure exceeds eighteen (18) inches, a fall zone is required. Ms. Mashburn stated that the program plans to remove the see-saw. Damaged material: Damaged materials shall be removed. The picture cube in space #1 shall be removed as part of the plastic were torn. QIRS discussion: During today’s visit QIRS was discussed with Ms. Mashburn as she had not chosen a pathway. Following is the summary of the discussion: Pathway: Ms. Mashburn had purchased Lillio Learning for Preschool Classrooms, though the program currently uses Creative Curriculum. Per statement, she had not purchased any formative assessment tools. Ms. Mashburn stated that she had not started using the Lillio curriculum yet but planned to transition in coming weeks and use the lesson plans provided by the curriculum. I reviewed the differences between Pathway 1: Program Assessment Pathway and Pathway 2: Classroom and Instructional Quality pathway. Program must go through ERS assessments, such as ITERS-3 and ECERS-3 with the Program Assessment Pathway while Classroom and Instructional Quality Pathway required program conducting formative assessment using approved formative assessment tool. For four-star level, all children must be assessed using approved formative assessment tool annually, and the results must be shared with families annually. I recommended Ms. Mashburn to choose Program Assessment Pathway because she had not purchased formative assessment tools yet. I shared that she had to apply for the Rated License Assessment by the end of September 2026. Due to staff members being unfamiliar with formative assessments and collecting artifacts, such as portfolio, work samples and anecdotal notes, learning formative assessments and conducting it for all children before the end of September, 2026 is unrealistic. During the conversation, Ms. Mashburn agreed to choose Program Assessment Pathway, though she wanted to consult with personnel from Buncombe Partnership for Children. The personnel is scheduled to visit sometime next week, per Ms. Mashburn, to provide consultation. Program Assessment pathway requires self-study. Self-study is required for administrator (Ms. Mashburn) and all lead teachers. Additionally, it must be minimum of three (3) consecutive month. You can learn more about self-study at https://ncrlap.org/ The program is open throughout summer, therefore, you must start self-study by beginning of June 2026, though it is strongly recommended to start it as soon as possible. Self-study must pertains to ITERS-3 or ECERS-3. Please consult with Buncombe Partnership for Children and see if they can provide you with ITERS-3 and ECERS-3 books. There are two (2) ways to choose topics of self-study: 1) Use the results of Outreach Assessment – you can schedule an Outreach Assessment by contacting NCRLAP at 1-866-362-7527. Depending on the volume of requests, NCRLAP may or may not provide you with an Outreach Assessment. I strongly recommend you contact them as soon as possible. Delaying this process may result in you not receiving the assessment. 2) Use self-assessment using the ITERS-3/ECERS-3 books. If you are unable to schedule an Outreach Assessment in timely manner, use the self-assessment section to identify the areas of needs and challenges. If you have additional questions regarding self-study, please contact me without delay. As the process takes minimum of three (3) consecutive months, delaying this process or leaving unanswered question may result in incompletion of this requirement. Education requirements: We discussed education requirements. Ms. Mashburn identified three (3) staff members as lead teachers and three (3) as teachers (teacher assistants). I explained that at least two (2) lead teachers and one (1) teacher must meet four-star level education to maintain the current star level. Note: Ms. Mashburn is expected to meet four (4) star level, though it is not guaranteed until all documents are reviewed and evaluated. For lead teachers to qualify for four-star level education, there are three (3) options. 1) Completion of at least twelve (12) semester hours in ECE/CD and two (2) years of experience. 2) Completion of Early Childhood Certificate 3) Five (5) years of early childhood work experience and either annual completion of 2.0 CEU’s or successful completion of competency evaluation. I explained that twelve (12) semester hours of ECE/CD means four (4) ECE classes that can be completed at accredited community colleges. EDU-119 is not included in the semester hours. The choice of 2.0 CEU’s equals twenty (20) hours of training. This requirement must be completed annually in addition to on-going training requirement. Most of the staff members have EDU-119, which requires ten (10) hours of on-going training. If you choose option (3), lead teachers must complete thirty (30) hours of training annually. Additionally, you must find training that offers CEU’s as it is required to be listed on the training certificates. CEU training costs and requires you to find them independently. We also discussed Competency Evaluation. The staff members who are recommended for Competency Evaluation must have in-depth knowledge of North Carolina Foundations for Early Learning and Development. Portfolio and additional documentations are required to be completed prior to receiving evaluation. I urged Ms. Mashburn to determine how to increase staff education as completing training or completing college courses may take time. The earliest staff members can enroll at this point is August. If you can find a college that offer summer classes, it may be possible to enroll in June. However, it is unlikely for staff members to earn twelve (12) credit hours before the end of September. Please review the Lead teacher education standard, which you can find on the QIRS information page at https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization One (1) of the teachers (assistant teachers) must meet one (1) of the following options for 4-star level: 1) Completion of NCECC and at least three (3) semester hours of ECE/CD and 1-year of experience. 2) Two (2) years of experience and annual completion of 1.0 CEU’s or successful completion of competency evaluation. 3) Active CDA An opportunity for free CDA course was shared with Ms. Mashburn via email on 2/13/36. Again, please contact me if you have any questions. It is strongly recommended to act as soon as possible. Without immediate action, it may result in reduction of stars. 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. 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 to 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 can be a resource for you while you strive to provide a safe and healthy environment for the well-being of young children. 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 .0601 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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 .0302 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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 .0902 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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 .1102 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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 .2830 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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. 110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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

GS 110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/4/2025 Number Present: 25 Completed Date: 11/4/2025 Age: From 0 To 4 Total Minutes: 454 Time In: 08:56 AM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance 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 Kathy Mashburn, Administrator, during the visit. A signed copy of the visit summary was electronically emailed to you. Today, Ms. Mashburn 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 eighty-four (84) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and Business Corporation, West Asheville Academy Inc., is current/active as of 11/3/25. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit with Rated License Assessment was conducted on 11/15/24. However, the Rated License Assessment did not proceed due to lack of sufficient education points to sustain the current star rating per Hold Harmless law. The last fire drill was practiced on 11/3/25. The last shelter-in-place drill was practiced on 11/3/25. The date on the log was written as 11/6/25. Per Ms. Mashburn, the drill was conducted yesterday, and the date was corrected during the visit. The last playground inspection was documented on 11/3/25. The last fire inspection was approved on 8/25/25. Fire Marshall came in during the visit and conducted an inspection during today’s visit. I worked in my state car during the inspection. The inspection was approved today. The last sanitation inspection was conducted on 1/29/25 with ten (10) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Lead water testing was completed on 8/29/23 without hazards. Lead paint and asbestos testing was completed on 5/28/24 and the program is exempt from further testing. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of seven (7) children were present. All were one (1) year of age, except for one (1) child, who was infant. The infant was held by a staff member, and others were walking around. Feeding plans, safe sleep poster and policy were posted. Diaper creams were stored appropriately and the permission forms were on file. In space #2, one (1) child had breakfast at a table and four (4) children engaged in play. A staff member sat by the table and supervised all children. One (1) therapist was present in the classroom. There was one (1) child, who was one (1) year of age, and the rest of the children were two’s. In space #3, a group of twelve (12) children, two (2) to four (4) years old were present. Six (6) children sat at a table with a staff member. Five (5) children played in block center and stacked wooden blocks on the floor. One (1) child connected letter puzzle pieces at another table. Per staff members, no emergency medications were maintained at this facility. Staff files were reviewed. Two (2) staff members files were monitored in full, while six (6) staff files were monitored partially for missing information. One (1) staff member was not listed on the Staff and Training Worksheet. Four (4) children’s files were reviewed. Playgrounds were monitored. Balance beams are connected. However, the bolts on the beams are not appropriately sized. This may cause safety concerns. If the bolts come out, it may create protrusions. I strongly recommend replacing the bolts and fit the holes for the beams. Additional, monitor the bolts closely, If it comes out, you must remove the bolts and the beams immediately. Your see-saw’s (duck and chipmunk) critical height was right at eighteen (18) inches off the ground. The fall zones had not been required or monitored by previous consultants or me. However, this may be cited by NCRLAP upon ERS-3 assessment. 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 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. Six (6) children were signed in when there were seven (7) children in space #1 - one (1) child's arrival time was not recorded. There were twelve (12) children while thirteen (13) children were signed in for space #3 - one (1) left before 9 am, but the time was not recorded. 10A NCAC 09 .0302(d)(4) 428 A current activity plan was not posted for each group of children for reference. In space #2, the posted activity plan was dated for 10/27/25 - 10/31/25. GS 110-91(12); .0508(a) 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. Three (3) feeding plans were not signed by the parents in space #1. .0902(a) 542 The written feeding plan was not modified as the child's needs changed. The feeding plans were not updated as children's needs changed Per interview, a staff member stated that eight (8) children out of nine (9) enrolled are on regular food. However, three (3) children's feeding plans were not modified to reflect the changes. 10 NCAC 09 .0902(a) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator temperature was fifty-two (52) degrees in space #1. 15A NCAC 18A .2806(j)(2) 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. In space #1, three (3) cribs were places right next to each other with no spaces among them. In space #3, two (2) cots in the housekeeping area were nine (9) inches apart. 15A NCAC 18A .2821(e) 616 Toys and other mouth-contact surfaces were not cleaned and sanitized daily when used or cleaned more frequently if visibly dirty. In space #3, seven (7) children and one (1) staff member sat at a table. One (1) was eating breakfast (waffles, syrup, pineapples and milk) and six (6) other children were playing with paper, crayons, baby dolls, pretend food, toy vehicles and pretend animals on the same table. The child who had breakfast cleaned the plate, sat at the table and played with other children. The table was not cleaned before or after. .2822(a)(1-4) 807 A safe indoor and outdoor environment was not provided for the children. In space #2, one (1) child's face was covered by his/her blanket. 10A NCAC 09 .0601(a) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. There were litter on the young children's playground including plastic cups, candy wrappers, and a broken plastic piece. 15A NCAC 18A .2832(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 can of Lysol aerosol spray was next to faucet for a sink by the changing table in space #1. .2820(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff member's record were not available for review. The staff was initially hired in 2009, left in 2023 and returned in 2024. Due to lack of documents, exact date of employment was not determined. G.S. 110-91( 9) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. .1103(a) 1320 Children's records that include an application for enrollment, medical and immunization records, and permission to seek emergency medical care was not on file for each child. A record of immunization was not in one (1) child's file. GS 110-91(1);.0302(d)(2); .0304(g) 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 members were listed on the center's roster on the ABCMS system. G.S. 110-90.2 & .2703(r) Technical assistance was provided as follows: 125: arrival and departure time Attendance records must include arrival and departure time of each child. To comply, staff members must review the attendance sheet and record each child’s arrival and departure time when he/she arrivals and departures. Otherwise, you can easily forget to record the times as you get busy doing other tasks. Inaccurate attendance records lead to supervision mistakes as well as other mistakes. In your compliance letter, please state the action you took to meet compliance. 428: Activity plans Activity plans must be current and posted for each group of children. To comply, please create the activity plan for this week and post it in space #2. In your lesson plan, you shall include all developmental domains listed on the NC Foundations books. Some Foundation books were shared with staff members during today’s visit. In your compliance letter, please state the action you took to meet compliance. 541: Feeding plan Feeding plans shall be signed and dated by the parents. Reference – 10A NCAC 09 .0902(a) 542: updates on feeding plan Feeding plans must be modified as the child’s needs change. Reference – 10A NCAC 09 .0902(a) Children with the following date of birth did not have a signature on the feeding plans: • 6/21/24 • 7/11/25 • 7/26/24 Feeding plans for the children with the following date of birth were not updated as their feeding needs changed. • 7/26/24 • 1/9/24 To comply, have the parents sign the feeding plans. Additionally, have feeding plans reviewed by the parents for all children under fifteen (15) months of age and update their feeding needs. Per interview, all children in space #1 but one (1) child is on regular meal. For children under fifteen (15) months of age, the feeding patterns need to be reflected. In your compliance letter, please state your actions to meet compliance. If your compliance letter, please state the actions you took to ensure compliance. 601: Refrigeration Refrigerators must be maintained at a temperature of forty-five (45) degrees or below. In space #1, temperature was fifty-two (52) degrees. To comply, please turn the temperature down and monitor the temperature. If it still does not fall, you may need to consider new thermometer or new refrigerator. In your compliance letter, please state your actions to meet compliance. 614: Space between cots Minimum of 18 inches are required between cots and cribs. There shall be at least eighteen (18) inches of space among cribs in space #1 or place plexiglasses on the side that are close to the other cribs. In space #3, two (2) cots in the housekeeping area were spaced approximately nine (9) inches apart. To comply, spread cots to make sure that they are at least eighteen (18) apart. Some centers use easily cleanable dividers to separate cots that are placed closer. In your compliance letter, please state your action you took to meet compliance. 616: health practice Equipment shall be cleaned and sanitized as needed to prevent the spread of germs. Children shall not play and eat at the same table at the same time. Tables shall be cleaned with soapy water and sanitized before eating. Any food and visibly dirty tables shall also be cleaned before children play. Your staff may require additional sanitation and safety training to minimize the spread of germs and communicable diseases. You can contact Child Care Health Consultant to discuss good hygiene practices in the classroom. Chrissy Wolfe, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC, 28806 Phone: 828-424-0562 chrissy.wolfe@mahec.net Robin Worley, BSN, RN, NCSN, CCHC-C/E Child Care Health Consultant 1100 Ridgefield Boulevard / Asheville, NC 28806 Phone: 828-772-0504 robin.worley@mahec.net In your compliance, please state the actions you took to meet compliance. 807: safe environment Children’s faces/head shall be uncovered after he/she falls asleep, if they cover themselves during rest time. Monitoring during rest time includes color check of each child, which require staff members to be able to see each child’s face. To comply, I recommend you review your supervision and safety policies during rest time with all staff members. In your compliance, please state the actions you took to meet compliance. 808: Litters on the playground Childcare premises must be free of litter and hazards. On the infant playground, there are some litters including small plastic wrappers, which are choking hazard for children under three (3). To comply, you must check the premises daily prior to children’s arrival. In your compliance letter, please state the actions you took to meet compliance. 840: Hazardous products Potentially hazardous products must not be accessible to children. A can of Lysol aerosol spray was located by the faucet by the sink by the changing table in space #1. To comply, remove the spray and store them in a locked storage. Baby proof devices are not considered sufficient for lockable storage. In your compliance letter, please state your action you took to meet compliance. 1043: Missing records The record of separation is dated 9/8/23. Per interview with C. Shearer, he/she has been back for approximately one (1) year. From this information, C. Shearer left employment at this facility around Sept. 2023 and returned around Sept/Oct. 2024. Therefore, C. Shearer is considered a new employee who started in Sept/Oct. 2024. C. Shearer needs updated forms listed below: • Employment application for 2024 • Orientation for 2024 • Health and Safety Training completed between Sept 2023 – current, if any. If not, the staff member must complete the training immediately. • Acknowledgement of center’s Shaken Baby Syndrome/abusive head trauma prevention policy. • Review of operational/personnel policy • Acknowledgement of receipt of job description • New medical statement • New TB screening 1052: On-going training Each staff member must complete required hours of training starting the second year of employment. The training period is determined based on each member of staff’s hiring date. The required hours are determined based on the education listed on his/her WORKS letter. It is important for each staff member and administrators to understand the accurate training period and required hours for each member of staff. During routine monitoring, I review the most recently completed training period. Following are the reviewed training period for each staff member during today’s visit. K. Mashburn – 12/31/23 – 12/30/24 K. Jones – 4/30/24 – 4/29/25 K. Benjamin – 10/7/23 – 10/6/24 J. Featherstone – 9/7/24 – 9/6/25 Other staff members’ second year training periods have not been completed. F. Payton’s current training period is 1/15/25 – 1/14/26 K. Sanders – 8/5/25 – 8/4/26 D. Davidson – 8/12/25 – 8/11/26 Based on the additional information on C. Shearer, his/her current training period is 11/1/25 – 10/30/26. Please note that K.S. and D. D don’t have their WORKS letters issued. Therefore, their required hours of training are twenty (20) hours. Based on the review of training certificates for above staff members, the following numbers of training were verified. Please note that First Aid/CPR training does not count toward on-going training hours, but ITS/SIDS does. K. Mashburn – required 8 hours, completed 10 hours K. Jones – required 10 hours, completed 6 hours K. Benjamin – required 10 hours, completed 6 hours J. Featherstone – required 10 hours completed 8 hours To comply, the following staff members must complete the listed hours of training within the next two (2) weeks. Those are the training hours to make up the previous training period. Therefore, the training hours to correct the violation cannot be counted toward current training period. K. Jones needs four (4) hours of training within the next two (2) weeks. K. Benjamin needs four (4) hours of training within the next two (2) weeks. J. Featherstone needs two (2) hours training within the next two (2) weeks. In your compliance letter, please verify the completion of training for each staff member. To make sure that those training will not be included in the current training, please list the names of training or scan the certificates and send them to me. 1320: Immunization record Immunization records are required to be maintained in each child’s file. To comply, please contact the parent of the child who is listed on the children’s files checklist and request his/her immunization record. In your compliance letter, please verify that the record is on file for the child. 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. 1898: Health and Safety Training The health and safety training shall include the following topic areas: (1) Prevention and control of infectious diseases, including immunization; (2) Administration of medication, with standards for parental consent; (3) Prevention of and response to emergencies due to food and allergic reactions; (4) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (5) Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event; (6) Handling and storage of hazardous materials and the appropriate disposal of biocontaminants; (7) Precautions in transporting children, if applicable; (Optional) (8) Prevention of shaken baby syndrome, abusive head trauma, and child maltreatment; You must keep all certificates to verify the completion of training. Health and Safety is valid for five (5) years. Some of your staff members may be missing “Medication in Child Care” training. In DCDEE Moodle, put “Medication” in the search box, find the training and complete it. Medication in Child Care training is not included in “CCDF” training. You must register for the training separately. In your compliance letter, please verify the completion of “medication in Child care” for the following staff members: • D. Davidson • F. Payton • J. Featherstone • 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 11/18/25. 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: WORKS account: Currently, four (4) staff members are assigned as lead teachers and two (2) staff members as teachers, per Staff and Training Worksheet. Two (2) teachers do not have WORKS letters issued. The email exchange in December 2024 reflects the years of experience and the WORKS letters. I reminded you that K. Sanders must submit an official high school transcript to his/her WORKS account. Please do so as soon as possible. Neglecting to update each staff member’s education on his/her WORKS account may result in inaccurate education evaluation for the Rated License Assessment. Please note that each staff member’s education must be reflected in his/her WORKS account, otherwise not considered sufficient to meet certain star level. Per email communication in December 2024, D. Davidson had less than one (1) year of verifiable child care experience as of December 12, 2024. K. Sanders had less than one (1) year of verifiable child care experience as of December 12, 2024, with submission of high school transcript to his/her WORKS account. Per email communication with Ms. Mashburn in December 2024, both K. Sanders and D. Davidson were planning to complete EDU-119 in January 2025. Both staff member will complete their EDU 119 by the end of December 2025, per Ms. Mashburn. Pathways: We discussed three pathways. However, the program doesn’t currently implement formative assessments. Therefore, pathway 1 is the best option. We discussed education requirements, CQI, family and community engagement, self-study, Outreach Assessment, CEU’s and other resources. Timeline: You can choose to apply in May 2026 or Early October 2026. By the time you sent the application for the Rated License Assessment, all work must be completed including update of WORKS account, Self-study, CQI, and family and community engagement activities. Based on the potential number of training hours required to meet the education standards, I recommend you October 2026. 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 .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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 .0803 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 .1102 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 .2830 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 11/15/2024 Number Present: 21 Completed Date: 11/15/2024 Age: From 0 To 4 Total Minutes: 237 Time In: 09:08 AM Time Out: 01:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp w/Rated Lic Assess Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance with 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 Katherine Mashburn, Administrator, during the visit. A signed copy of the visit summary was printed and left on-site with you. Ms. Mashburn was available during the visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-five (85) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy Inc. is current/active as of 11/12/24. Permit type – four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhance ratios and space. The last annual compliance visit was conducted on 5/14/24 The last fire drill was practiced on 10/31/24. The last shelter-in-place drill was practiced on 5/3/24. The last playground inspection was documented on 10/22/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old child engaged in various activities. Two (2) children arrived during the observation. Both children washed their hands before engaging in activities. The children moved around the room or sit with a teacher and played with rattles and other materials. One (1) child’s diaper was changed during the observation. Space #2 was not in use during the visit. Three (3) children in this space was included in space #3. In space #3, a group of two-to-four-year-old children engaged in free play with manipulatives, blocks, and music instruments. Three (3) children, two (2) years of age, were from space #2. Interaction and supervision were adequate. No emergency medication is maintained at this facility currently. Children had hotdog, baked beans, mandarin oranges and crackers and milk for lunch. Per facility’s Emergency Operation Plan for boil water notice, water containers with spigot are set up in each sink including bathroom sinks and classroom sinks. Regular sinks are tapes indicating that they are not in use. Two (2) new staff files, two (2) existing files and three (3) children’s files were monitored. Due to the effect of Tropical Storm Helene, technical assistance were provided for items listed on the Staff and Training Worksheet. 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 541 The written feeding plan did not include the child's name, parent signature, and/or was not dated when received by the center. A feeding plan in space #1 was posted but not signed by the parent. .0902(a) 608 Children did not wash their hands upon arrival at the center, after each visit to the toilet, before eating, before and after water activity play, after outside play, and after handling animals or animal cages. A child's hand wash not washed after diaper change in space #1. 15A NCAC 18A .2803(c) 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. Staff member did not wash hands after changing a child's diaper in space #1. 15A NCAC 18A .2803(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, two (2) Nystatin creams were maintained in a plastic shoe-box container in the cubby above five (5) feet along with other over-the-counter diaper creams. 15A NCAC 18A .2820(d) 847 Parent's medication authorization did not include required information. The medication authorization for Dentin in space #2 was dated 5/12/23. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. Aquaphor Healing Ointment Baby for a child expired in September, 2024 in space #1. .0803(12) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. Three packs of napkins (Smart & Simple, Great Value, Kirkland) were stored on top of the cabinet by the entrance door in space #1. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Last lockdown drill was completed on 5/3/24. .0604(u);.0302(d)(8) Technical assistance was provided as follows: Staff and Training Worksheet: It is important to record accurate dates on the Staff and Training Worksheet. Please see the following items. Orientation: All the topics listed on the orientation sheet shall be reviewed with each staff upon initial hiring. Health and Safety training cannot be counted as orientation. You shall discuss how your facility mange each topic area. For example, you can discuss location of your vomit kit and ways you recommend your staff members to handle bodily fluid. Check marks are not accepted fort his section. First Aid/CPR date: On the Staff and Training Worksheet, please put expiration date of the training rather than the date of training. Emergency information form is not a confidential information by the Divisions definition. Therefore, emergency information form shall be maintained with other documents, such as application, staff development plan and on-going training certificates. Confidential information pertains to any types of health information, including but not limited to health questionnaire, TB screening, and medical statement. Health and Safety training and on-going training: All completed training certificates shall be in file to verify the training hours. Operational policies (OP) /personnel policies (PP): the date you reviewed your center’s operational policies and personnel policies shall be logged. To-do: • Two (2) staff members, hired on 8/5/4 and 8/12/24 shall print Recognizing and Responding to Suspicions of Child Maltreatment training certificate and maintain them in their files. • The staff member hired on 8/12/24 shall complete missing Health and Safety training on or prior to 8/12/25. • All staff members shall review some topics and complete orientation. Please update all staff member’s orientation forms upon completion of the training. • The staff member hired on 10/7/10 has completed 5.0 hours of verifiable on-going training between 10/7/23 to 10/6/24. This staff member is required to complete minimum of ten (10) hours of training annually. • The staff member hired on 10/7/24 has expired Health Questionnaire form. • Health questionnaire for the staff member hired on 9/7/23 is expired. Please renew the form. Technical assistance on violation items: 541: Feeding plan Feeding plans shall be signed and dated by the parents. There is one (1) child’s feeding plan in space #1 that is not signed. Please ask the parent to sign the form. Infant feeding is unique to each individual child. The parents shall be fully aware of the plan and consent to it. 608: Handwashing – child Per 15A NCAC 18A, .2803, Children are required to wash their hands upon arrival, upon diapering/toileting, before meal, upon coming back from outside and as needed basis. The child’s hands must be wiped by baby wipes during diaper changing procedures then washed with soap and running water. Please review the handwashing procedures as well as diaper changing procedures with your staff members. 609: Handwashing – staff Per 15A NCAC 18A .2803, Staff members are required to wash their hands 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. Handwashing is the most effective way to prevent bloodborne illnesses and other types of germs. Please review the diapering procedures as well as handwashing requirements with your staff members. 841: Medication storage Per 15A NCAC 18A .2820(d), all non-emergency prescription medication shall be stored in a locked storage including prescription ointment used as diaper cream/ointment. Please store two (2) Nystatin in space #1 in a storage with lockable device. There is a tool box with a lock in space #2. A similar container is recommended. 847: Permission form for over-the-counter medication Per 10A NCAC 09 .0803(4)&(6-9), parental authorization to administer medication is required for all medications including over-the-counter lotions and diaper creams. The permission form is valid for over-the-counter creams for up to twelve (12) months. The authorization form for prescription is up to six (6) months. Please use the form for prescription for Nystatin in space #1. The permission form for Destin in space #2 expired on 5/12/24. The form shall be renewed or the medication shall be returned to the parent. 849: Expired medication Per 10A NCAC 09 .0803(12), all expired medications shall be returned to the parents or discarded within seventy-two(72) hours of their expiration date. Aquaphor Healing Ointment Baby is expired on 09/2024 in space #1. Please send the medication home today. 861: Easily torn plastics Easily torn plastics are considered choking and/or suffocation hazard for children under three (3) years of age. There are three (3) packs of napkins stored on top of the cabinet by the door in space #1. Please store them in a cabinet with baby-proof device, at least five (5) feet or above or in a locked storage. 1811: Lockdown drill Lockdown drill is required for every three (3) months. Your last lockdown drill was 5/3/24, therefore it was due in August. Please conduct lockdown drill immediately. 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 I must receive your compliance statement by 11/29/24. 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 Address: 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: Staff/child ratios: Staff/child ratios as well as supervision must be met at all times. When children need diaper changing while the group is on the playground, all teachers must maintain the ratios at all times. This may require a teacher to bring more than one (1) child to the classroom to make sure that the other teacher(s) on the playground maintain the required ratios. Based on the avers ERS score and the restrictions, the program scored six (6) points for the Program Standards. Rated License Assessment: West Asheville Academy received the Prep-year Assessment. On July 16, 2024, ECERS-R assessment was conducted and the program scored 5.0. On July 20, 2024, ITERS-R assessment was conducted and the program scored 5.13. The average score between two assessments is 5.07. This score will be used to determine part of the program points. The program meets enhanced ratios and space. Quality point was discussed. Per discussion with Ms. Mashburn, “the child care administrator has at least 10 years of documented child care administrative work experienced in a license program that can be verified by the Division”. The program’s temporary license was issued on 8/25/2008. Education point: Education points will be determined based on each staff member’s WORKS letter. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 .0901 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0508 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0604 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0605 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0713 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0901 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .1801 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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.S110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 8/8/2024 Number Present: 22 Completed Date: 8/8/2024 Age: From 0 To 5 Total Minutes: 202 Time In: 08:58 AM Time Out: 12:20 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 Prep-Year Environment Rating Scale assessment. Ms. Mashburn was on-site and available to answer and ask questions. 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 Katherine Mashburn, Administrator, during the visit. The signed copy of the visit summary was printed and left with you. The ITERS-R assessment was conducted on 7/30/24 with the score of 5.13, the ECERS-R was conducted on 7/16/24 with the score of 5.0. All ERS items scoring below five (5) points were discussed with the ERS Assessment Facility Summary Report and the Documentation of ERS Review tool. Limited monitoring was conducted today, including the items scored low on ITERS-R and ECERS-R. In space #1, a group of six (6) children, zero-to-one year of age, explored the environment. One (1) teacher changed a child’s diaper, and the other teacher supervised the rest of the children. Diaper changing procedures were appropriately followed. In space #2, three (3) children, one-to-two years of age engaged in free play. The children played with blocks with a teacher. In space #3, thirteen (13) children, two-to-five years of age engaged in free play. The children played with dress-up clothes, blocks and toy people. Twice during the observation, one (1) teacher took a child to the bathroom in the hallway. Interaction between teachers and children were adequate. One (1) new staff file was monitored. The staff’s date of employment is 8/5/24. All pre-employment paperwork were in file, including medical statement, TB screening and criminal background letter. Other post-employment paperwork was also in file. Orientation, health and safety training were still in progress. ERS review and monitoring of related items: ECERS-R Item 6: Children’s work This is not a licensing requirement. Item 7: Depth of loose surfacing Per Child Care rues, a fall zone is required for the gross motor equipment with critical height over eighteen (18) inches above the ground. The two-person seesaw’s critical heigh was measured for seventeen (17) inches and the animal spring rockers’ critical heights were eighteen (18) inches. Per 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (a) (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either, the licensing require fall zone for equipment with the critical heigh of over eighteen (18) inches. Item 8: Gross motor activities When you think about gross motor activities, try to address different gross motor skills rather than different activities. Per NC Foundations for motor development for preschoolers, balance, coordination, such as throwing and catching, use of gross motor equipment, such as balls, slides, pedaling toys, running, hopping, galloping, skipping are mentioned. Item 9: arrival and departure procedures Even though parental access to the facility during operating hours must be granted, it is not a licensing requirement to require parents to be in the classroom. The children’s arrival time was appropriately recorded in space #3 during my observation. Item 10: nurture and care of children This is concerning report. Even though there are times when isolating a child can be an effective approach, the child should be re-introduced to the rest of the group of children as soon as he/she/they is ready to do so. The child shall not be routinely isolated form the rest of the group based on the assumption that he/she/they may misbehave. Per G.S110-91 (10) each child shall be attended in a nurturing and appropriate manner, or in keeping with the child’s developmental needs. I observed the lunch time. In space #3, all children were seated between two (2) tables, including a child with disabilities. I advised the teachers to place the child on the same table, leave a space next to him/her/them, if possible, to reduce the chance of the child grabbing other children’s food. One (1) teacher sat next to the child to supervise. Item 13: Handwashing Following is the handwashing rule: 15A NCAC 18A .2803 HANDWASHING (a) Child Care operators shall instruct employees that handwashing is the single most important line of defense in preventing the transmission of disease-causing organisms. Employees shall wash hands upon reporting for work; before and after handling food; before bottle feeding or serving to other children; before handling clean utensils or equipment; after toileting or handling of body fluids (e.g., saliva, nasal secretions, vomitus, feces, urine, blood, secretions from sores, pustulant discharge); after diaper changing; after handling soiled items such as garbage, mops, cloths and clothing; after being outdoors; after handling animals or animal cages; and after removing disposable gloves. The use of hand sanitizing products does not replace the requirement for handwashing. However, except for diapering, food preparation, and food service, hand sanitizing products may be used in lieu of handwashing while an employee is supervising children outdoors if hands are washed upon returning indoors. (b) Children shall wash hands upon arrival at the child care center; after each diaper change or visit to the toilet; before eating meals or snacks; before and after water play; after outdoor activity; and after handling animals or animal cages. Except for diapering and before eating meals or snacks, hand sanitizing products may be used in lieu of handwashing while children are outdoors if hands are washed upon returning indoors. I observed the handwashing procedures in space #1 during diaper change. Handwashing of the child and the teacher was appropriate. Item 14: Potential choking hazard Small toys are prohibited for children under three (3) years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. All objects mentioned are considered choking hazard for children under three (3) years of age. Item 17 and 18: Critical Thinking Per below rules, cognitive development, including critical thinking shall be included in the daily activities. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. During the observation today, there were no conversations that promote critical thinking between the teachers and the children. Item 20: Art materials Art materials were provided to the children. Multiple categories of art materials are not a licensing requirement. On the lesson plan in space #3, shapes, counting, coloring, tracing letter, cutting, rainbow necklace and relay race were listed for this week. Those activities cover all domains listed in NC Foundations. However, teachers have the critical role in the most effective implementation of those activities that promotes all the development. Without appropriate guidance and conversations, the activity or materials alone is not sufficient. Please be mindful of the role of the teacher in activities. Item 21: Music This is not a licensing requirement. Item 22: blocks Quantities and typus of blocks are not a licensing requirement. Item 25: Science This is not a licensing requirement. Involving children in learning can be an effective ways to learn any topics including science. Item 26: Math Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. I observed counting materials, including counting car & people, abacus and shapes in the classroom. Item 33: Problem-solving skills Problem solving and conflict resolution shall be part of social emotional and language development. The children need to be guided and included in the problem-solving process daily to nurture health social/emotional development. Math activities shall be part of cognitive learning on a daily basis. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. Overall: Please review your daily activities, learn North Carolina Foundations and include cognitive learning, social/emotional learning, approaches to learning and language/communication into your daily routine to strengthen your program. ITERS-R: Item 6: Arrival and departure process Even though this is not a licensing requirement, daily communications with parents are important. Encourage parents to visit the classroom and communicate with teachers. Item 7: Nutrition requirements Per rule below, water shall be freely available to children of all ages. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (e) Drinking water shall be freely available to children of all ages. Drinking fountains or individual drinking utensils shall be provided. When a private water supply is used, it must be tested by and meet the requirements of the Commission for Public Health as set forth in 15A NCAC 18A .2800. Per interview with Ms. Mashburn, a child in space #1 is not served with milk per parent request but there was no documentation regarding the special diet. Ms. Mashburn contacted the parent during the visit to collect the documentation of parent preference. Milk is required as a component required by USDA. (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. Per supervision rule, staff must be able to see and hear children while they are eating. At least one (1) staff members should be watching children eating at all times and not engaged in any other activities due to choking potentials, especially for younger children. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (5) staff must be able to see and hear children aged birth to five years old while the children are eating. During meal time in space #3, one (1) teacher took a child to space #2 to be changed, and the other teacher placed cots in the classroom. During the time, no teachers’ eyes were on the children eating for short period of time. In #2, one (1) teacher walked to the door while three (3) children were at the table eating. Since this is the first time I had a conversation regarding supervision during meal time with Ms. Mashburn, I will provide technical assistance. However, this will be cited as a violation moving forward. At least one (1) teacher shall be monitoring meal time at all times. Item 9: Change of use of sink 15A NCAC 18A .2818 LAVATORIES (c) Lavatories shall be cleaned and disinfected with each change of use, as needed and at least daily. A disinfecting solution as set out in 15A NCAC 18A .2801(7) shall be used for this purpose. A testing method shall be made available to ensure compliance with the prescribed bleach solution concentration. To achieve the maximum germ reduction with bleach, the cleaned surfaces shall be left glistening wet with the bleach solution and allowed to air dry or be dried only after a minimum contact time of at least two minutes. Products registered with the U.S. Environmental Protection Agency as hospital grade germicides or disinfectants or as disinfectants for safe use in schools, child care centers, institutions and restaurants are also approved disinfectants, provided the manufacturer's Material Safety Data Sheets are kept on file at the child care center and the instructions for use are followed. Item 10: Handwashing This was discussed for ECERS-R. Item 14: Books The quantities and the types of books are not licensing requirement. Item 15: Blocks The quantities and the types of blocks are not licensing requirement. Item 17: Art This is not a licensing requirement. Item 20: dramatic play The quantities and types of dramatic play materials are not licensing requirements. Item 29: Waiting time Even though this is not a licensing violation, reducing waiting time is important strategies for behavioral management and effective nurture and care. Item 32: Working with children with disability This is not a licensing requirement. 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 violations of child care requirements observed: Violation Number Comment Rule 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. A three-year-old child from space #3 was taken to space #2 for diaper change. The teacher from #3 left the three-year-old child from space #3 with a teacher in space #2. At the time of the incident, there were one (1) teacher with three (3) children, one-to-two years of age, were present in space #2. 10A NCAC 09 .0713(a)(6) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Per interview, a child, one (1) year of age, in space #1 is not served milk due to parent preference. No notes has been obtained. 10A NCAC 09 .0901(a) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. I observed some prohibited items in space #2 and #3. In space #2, there were a grocery bag, a packet of Hersey’s chocolate package and a bag of large marshmallows on top of the shelf with height of approximately thirty-six (36) inches. The marshmallows are cylinder shape with 1 ¼ inch diameter. In space #3, there were counting toy with cars and pretend people. The people toy was ¾ inches in diameter, ¾ and two (2) inches long. .0604(q) Technical assistance for correction plan: 318: Staff/child Ratio and grouping of children Per interview with Ms. Mashburn, a child, three (3) years of age from space #3, visits #2 for diaper change. During the visit, the child from space #3 was dropped off in space #2 for diaper change to be completed by the teacher in #2. The teacher in #2 is the foster parent of the child. However, if the foster parent has responsibilities to care for other children, the person shall be considered teacher rather than a parent. Additionally, the three-year-old child from space #3 was grouped with the children in space #2, who were one-to-two years of age when the teacher from #3 left the classroom. Therefore, this is a violation of staff/child ratio. You can use mat to change the child’s diaper in the bathroom and/or change the diaper while the child is standing. There are other ways to accommodate the child’s needs outside of space #2. (a) The staff/child ratios and group sizes for single-age groups of children in centers shall be as follows: Age of 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (6) except as provided in Subparagraph (2) of this Paragraph, children between the ages of 12 months and 24 months shall not be grouped with older children unless all children in the group are less than three years of age; 501: Meal pattern Milk or milk substitute item counts as one component. If a child has medical condition, religious preference, cultural preference and/or personal preference, acceptable substitute item shall be served that meets the USDA requirements. Juice or water do not meet as a milk substitute. Acceptable milk substitutes are lactose-free milk, soy milk or split pea milk. Please obtain a note from the child’s parent and post the note in the kitchen and classroom. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (a) Meals and snacks served to children in a child care center shall comply with the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA) which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. The types of food, number and size of servings shall be appropriate for the ages and developmental levels of the children in care. The Meal Patterns for Children in Child Care Programs are incorporated by reference and include subsequent amendments. A copy of the Meal Patterns for Children in Child Care Programs is available online at https://www.fns.usda.gov/cacfp/meals-and-snacks. 858: potential choking hazards Small toys and easily torn plastics are considered choking hazard for children under three (3) years of age. Those materials shall be maintained at least five (5) feet above or stored in the storage with baby proof device or a lock. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Corrective Action Plan: Due to item 318 per 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS, a follow-up visit may be required. Please submit a letter of compliance for the items 501 and 858 following the instructions below: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license could be issued. 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 I must receive your compliance statement by 8/22/24. Email the compliance letter on signed letterhead or on 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 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 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. Falsification of any information may result in a revocation of your license. 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. Consultation: Grouping of children: We discussed a child in group #3. This is non-verbal and developmentally not able to participate in activities with other children. Please involve the parent/guardian and physician into the conversation regarding the appropriate placement of this child. 10A NCAC 09 .0713 STAFF/CHILD RATIOS FOR CENTERS (3) a child two years of age and older may be placed with children under one year of age when a physician certifies that the developmental age of the child makes this placement appropriate; Rated License Assessment; Per Ms. Mashburn, she would like to renew the Rated License if she could maintain the same star rating or better. I will review the staff members’ education and notify you about potential education points. I will conduct Rated License assessment visit prior to renewing the Rated License process. Special diet: The information on the children with special diet shall be posted in the food preparation area and in the child’s eating area. The food can be provided by the center or by the parent. The special diet can be accommodated for medical, religious, cultural or personal preferences. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (g) Children's special diets or food allergies shall be posted where they can be seen in the food preparation area and in the child's eating area. (h) The food required by special diets for medical, religious, or cultural reasons, or parental preferences, may be provided by the center or may be brought to the center by the parents. If the diet is prescribed by a health care professional, a statement signed by the health care professional shall be on file at the center and written instructions shall be provided by the child's parent, health care professional, or a licensed dietitian/nutritionist. If the diet is not prescribed by a health care professional, written instructions shall be provided by the child's parent and shall be on file at the center. 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. 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 .0302 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0508 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0604 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .1102 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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

GS 110-91 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 5/14/2024 Number Present: 31 Completed Date: 5/14/2024 Age: From 0 To 5 Total Minutes: 250 Time In: 09:05 AM Time Out: 01:15 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 Kaoru Eddins, Child Care Consultant and also signed by Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Ms. Mashburn 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 seventy-eight (78) percentage as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and the business corporation, West Asheville Academy is current/active as of 5/9/24. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 5/3/24. The last lockdown drill was practiced on 5/3/24. The last playground inspection was documented on 5/9/24. The last fire inspection was approved on 1/22/24. The last sanitation inspection was conducted on 12/8/23 with fifteen (15) demerits for a superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response Plan was last updated on 10/24/23. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, I observed a group of infants and one-year-old children explored the environment. Some children walked around the room, and others sat and played with rattles. Diaper creams were stored appropriately. All permission forms were valid. One (1) prescription cream was stored in a unlocked storage. Feeding plans were signed by the parents and posted. Sleep checked were conducted adequately. There were two (2) evacuation cribs in the room. In space #2, a group of one-to-two-year-old children engaged in free play. The children played with dress up accessories, balls, instruments, and other materials. The teacher conducted a group time and sang songs with the children to review days and months. The group time was interactive. Diaper creams were stored in a tool box on the counter at approximately forty-one (41) inches. There were some plastics accessible to the children on the shelf at approximately thirty-four (34) inches high. In space #3, a group of two-to-five-year-old children engaged in free play. The children played with housekeeping accessories, blocks, manipulatives and other materials. There is a cleaning spray with multiple warnings, including flammable warning. Per Ms. Mashburn, this item was discussed with the Environmental Health specialist and was approved. Two (2) playgrounds were monitored. The infant playground is renovated. Artificial grass turf was placed on the ground. Ms. Mashburn is expecting a shaded structure to be delivered for the playground next week. On the older children’s playground, there were riding toys, portable slide structures, tunnels, rockers and other materials available. Lunch was served during the visit. Today’s menu was chicken nuggets, tortilla chips and crackers, pineapples, apple sauce and milk. These items were not listed on the menu originally, but the items were written on the menu before serving the children. One (1) existing staff file and one (1) new staff member’s file was reviewed in full. Other staff member’s files were reviewed for missing dates on the Staff and Training Worksheet. Four (4) children’s files were monitored. 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 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. There were no arrival time logged for five (5) children present at 9:20 am in space #1. 10A NCAC 09 .0302(d)(4) 415 A current schedule was not posted for each group of children for reference. No schedule was posted in space #1. GS 110-91(12);.0508(a) 428 A current activity plan was not posted for each group of children for reference. This week's activity plan was not posted in space #1. Lesson plan posted in space #2 was dated 5/6/24 - 5/10/24 GS 110-91(12); .0508(a) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Nystatin was stored with other diaper cream in space #1.In space #2, a diaper creams in a tool box was maintained on the shelf at approximately forty-one (41) inches high. 15A NCAC 18A .2820(d) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Member's Mark paper Plate in plastic bag was stored on the shelf at approximately thirty-four (34) inches high in space #2. On the same shelf five (5) mini candy bars and one (1) Austin Cheddar Cheese crackers were stored. .0604(q) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. The staff member hired on 1/15/24 did not complete the training within ninety (90) days of employment. .1102(g) Technical assistance was provided as follows: 125: arrival and departure time Arrival and departure time shall be logged upon each child’s arrival and departure. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (d) During the pre-licensing visit the applicant shall have the following available for review pursuant to 10A NCAC 09 .0304(g): (4) daily records of arrival and departure times at the center for each child which shall be maintained as children arrive and depart; 415: Schedule Schedule for each group of children shall be posted in the classroom. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 428: Activity Plan The activity plan shall designed to stimulate emotional and social, health and physical, approaches to play and learning, language development and communication, and cognitive development for each group of children in care. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. 841: Storage of Medication Prescription diaper cream, such as Nystatin, shall be stored in a locked storage. Additionally, the permission form shall be valid for six (6) months and the use of the medication must be logged. This was corrected during the visit by removing the medication from the classroom and stored in a locked storage in the office. Non-prescription diaper cream shall be stored out of reach of children at least five (5) feet or above. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use, but are not required to be in locked storage. 858: Plastics Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed shall not be accessible to children under three years of age. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1897: Recognizing and Responding to Suspicions of Child Maltreatment Training 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: 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 I must receive your compliance statement by 5/28/24. 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: Prep-year assessment application was printed and shared with Ms. Mashburn. Ms. Mashburn filled out the form and submitted it to me during the visit. West Asheville Academy is in cohort one (1). Orientation topics: All orientation topics shall be covered with new staff members during orientation. The topics overlaps with some Health and Safety training topics. However, what you must cover during orientation is what pertains to your facility. For example, location of biohazard cleaning supplies and the procedure of clean up shall be discussed for the infectious disease prevention, and what procedures to follow, who to contact, etc should be discussed for food allergic reaction. Please make sure to cover all the topics and log the date of review. Confidential information: The emergency information form shall be maintained with regular files. Confidential information is medical statement, TB screening and health questionnaire form. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0601 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0604 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0605 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0607 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0801 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .0803 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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 .1102 · Violation

Name of Operation: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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: WEST ASHEVILLE ACADEMY Facility ID: 11000741 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 10/23/2023 Number Present: 28 Completed Date: 10/23/2023 Age: From 0 To 4 Total Minutes: 210 Time In: 09:00 AM Time Out: 12:30 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 an annual compliance visit. 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 Katherine Mashburn, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed you. Today, Katherine Mashburn, Administrator, was available during today’s visit. The indoor and outdoor areas were monitored today, including but not limited to 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 eighty-one (81) percentage as of 10/16/23. Permit type – Four-star center license issued on 4/6/18. Special Services/Restrictions – daytime care, meets enhanced ratios and space. The last annual compliance visit was conducted on 5/17/23. The last fire drill was practiced on 9/7/23. The last shelter-in-place drill was practiced on 9/7/23. The last playground inspection was documented on 9/13/23. The last fire inspection was approved on 4/3/23. The last sanitation inspection was conducted on 12/15/22 with eight (8) demerits for a superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness and Response (EPR) plan was last updated on 6/1/22. The approved curriculum for four-year-old children is Creative Curriculum. Upon arrival, I announced my presence and the purpose of the visit. In space #1, a group of infants and one-year-old children engaged in free play. Some of the children ate cereals on the feeding tables, other children explored materials, such as rattles and noise makers. One of the children was held by a teacher and fed a bottle. In space #2, a group of one-to-two-year-old children engaged in free play using books, large counters, baby dolls, blocks, utensils and cups. One of the one-year-old children was moved to space #1 temporarily until the second teacher arrived. In space #3, a group of two-to-four-year-old children engaged in free play. The children played with science/math materials, manipulatives, puzzles, housekeeping toys and blocks. Some children made pretend meals. In space #3, sixteen (16) children attended today, one of the children are school-age children who attends in the morning before he/she goes to school. Fifteen (15) children, two-to-four years of age were present in space #3 during the visit. Playgrounds were monitored. There is a small playground for infants and a large playground for toddlers and preschoolers. On the large playground, there are riding toys, bike circle structures, metal vehicle seats, see-saws, a slide structure and play houses. There is one(1) child on emergency medication. An action plan expired on 10/14/23 and no permission form was not in file or with the medication. The last date when the medication was administered was in August 2023. Four (4) children in space #1 fell asleep around 11:15 am. Three (3) children laid on the back in the crib and one (1) child slept on the cot. Sleep checks were filled out. Lunch was served during the visit. The items served for lunch were chicken stir fry with rice, mixed veggies, mixed fruits and milk. The items were listed on the menu. Space #3 was observed. The group of children used bathroom sink to wash hands, sat on the table and ate the meal. Two (2) new staff member's files were monitored in full. Four (4) existing staff files were monitored for training and criminal background letters. All existing staff member hold valid CPR/First Aid certificate and criminal background letter. 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/ This facility does not provide transportation. The following violations were documented during today’s visit: Violation Number Comment Rule 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were rust on the handles of bikes (bike circle structure), and rust on the metal bars on the seat structure with three (3) handles. .0601(c) 808 The outdoor premises were not clean, drained and free of litter and hazardous materials grass and other vegetation in a manner which does not encourage vermin. On the small playground, there were two paper cups and a Butterfinger candy wrapper on the ground. 15A NCAC 18A .2832(a) 829 Gas tanks, gas, and/or charcoal grills, were not inaccessible or in a protective enclosure, making them accessible to children. A charcoal grill was accessible to children on the small playground. .0604(n) 847 Parent's medication authorization did not include required information. There were no medication authorization form for review for Albuterol in space #3. 10A NCAC 09 .0803(4)(6-9) 861 Prohibited styrofoam and foam rubber products were accessible to children under 3 years of age and/or approved foam products were used without proper supervision. In space #2, a dollar tree grocery bag and coffee filters in plastic wrapper are stored on top of the shelf by the door. .0604(q) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The facility's EPR plan was last reviewed and updated on 6/1/22. .0607(e) 1835 The medical action plan was not updated on an annual basis or when changes to the plan were made by the child's parent or health care professional. A child's medical action plan for Albuterol expired on 10/14/23 in space #3. .0801(b) Technical assistance was provided as follows: 705: Rust Equipment shall be hazard free. They have to be free from rust. 10A NCAC 09 .0601 SAFE ENVIRONMENT (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. 808: Free of litter Outdoor playground shall be free of litters. 15A NCAC 18A .2832 OUTDOOR LEARNING ENVIRONMENT AND PREMISES (a) At child care centers, the premises, including the outdoor learning environment, shall be kept clean, drained to minimize standing water, free of litter and hazardous materials, and maintained in a manner which does not encourage the harborage of vermin. All debris, glass, dilapidated structures and broken play equipment shall be removed. Wells, grease traps, cisterns and utility equipment shall be made inaccessible to children. 829: Charcoal grill Charcoal grills shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (n) Gas tanks and gas or charcoal grills shall be inaccessible to children or shall be in a protective enclosure. 847: Authorization to administer medication Authorization to administer medication form shall be valid at all times when a medication is maintained at the facility. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS (6) A parent may give a caregiver standing authorization for up to six months to administer prescription or over-the-counter medication to a child, when needed, for chronic medical conditions, such as asthma, and for allergic reactions. The authorization shall be in writing and shall contain: (a) the child's name; (b) the subject medical conditions or allergic reactions; (c) the names of the authorized over-the-counter medications; (d) the criteria for the administration of the medication; (e) the amount and frequency of the dosages; (f) the manner in which the medication shall be administered; (g) the signature of the parent; (h) the date the authorization was signed by the parent; and (i) the length of time the authorization is valid, if less than six months. 859: Playground inspection Playground inspection shall be conducted monthly. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (q) Following completion of playground safety training as required by Rule .1102(e) of this Chapter, a monthly playground inspection shall be conducted by an individual trained in playground safety requirements. A trained administrator or staff person shall make a record of each inspection using a playground inspection checklist provided by the Division. The checklist shall be signed by the person who conducts the inspection and shall be maintained for 12 months in the center's files for review by a representative of the Division. The playground inspection checklist may be found online at https://ncchildcare.ncdhhs.gov/providers/credent.asp. The playground inspection includes a checklist of items related to safety, surfacing, and equipment quality. 861: Easily torn plastics Easily torn plastics, such as grocery bags, Ziplock bags and other plastic wrappers shall be inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. 1824: Emergency Preparedness and Response (EPR) plan EPR plan shall be reviewed and updated annually. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. 1835: Medical Action Plan An action plan shall be renewed annually. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. Sample medical action plans may be found on the Division's website at http://ncchildcare.ncdhhs.gov Corrective Action Plan: 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 I must receive your compliance statement by 11/6/23. 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: Change of use for a sink: Before a sink is used for different purposes, the sink used for bathroom use shall be disinfected. For consultation for the use of sink, please contact your environmental health specialist or child care health consultant. Supervision of children: There were fifteen (15) children present in space #3, and both teachers thought that there were fourteen (14) children. The fifteenth (15) child was new and was not listed on the attendance sheet. Knowing how many children are present is the first step is to maintain supervision of children. Teachers should take head counts/name to fact counts upon each transition to prevent supervision mistakes on a daily basis. Use of curriculum: The curriculum should be reflected in your lesson plans. Lesson plans shall reflect all developmental domains covered in the curriculum, such as social/emotional, physical, language/Literacy, cognitive, executive function, creative arts. Rated License Cohort: West Asheville Academy is in cohort one (1). Your prep-year is current, and the assessment year will be July 2024 to June 2025. We have discussed prep-year assessment and WORKS account review. BSAC training: An administrator and the teacher(s) who is responsible for school-age care shall obtain BSAC training certificates. If you have any questions or concerns regarding the Stabilization, Expansion and Access Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. 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. 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. 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. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. 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. 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 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. 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