Supervision
Name of Operation: ACADEMY AT BILTMORE CHURCH Facility ID: 11000943 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 12/4/2025 Number Present: 112 Completed Date: 12/4/2025 Age: From 0 To 5 Total Minutes: 290 Time In: 09:10 AM Time Out: 02:00 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 Shannon VonKaenel, Director, during the visit. Dawn McCrary, Child Care Consultant accompanied me to this visit. A signed copy of the visit summary was left on-site and electronically emailed to you. Today, Ms. Lovelace 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-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 non-profit corporation, Biltmore Baptist Church, is current/active as of 12/3/25. Permit type – G.S.110-106 issued on 10/10/24. Special Services/Restrictions – daytime care and children in care on ground level only. Per Ms. Lovelace, the program receives subsidies. Our system will be updated to reflect the change. The last annual compliance visit was conducted on 12/10/25. The last fire drill was practiced on 11/12/25. The last shelter-in-place drill was practiced on 9/30/25. The last playground inspection was documented on 11/25/25. The last fire inspection was approved on 1/30/25. The last sanitation inspection was conducted on 11/21/25 with six (6) demerits for a superior classification. The Emergency Medical Care plan was posted and current. Lead water testing was completed on 3/24/21 without hazards. No records were available for lead paint and asbestos. Forty-one (41) staff members were listed on the ABCMS roster as of 12/3/25. Upon arrival, we greeted and announced the purpose of the visit. Walk-through of classrooms: There were multiple classrooms being closed for staff shortages. The children enrolled in those spaces were combined with other classrooms. Those spaces were 407, 409 and 422. Combined classroom and transitioning: Children in 409 was combined with children in 408, while the children in 422 was spread between 421 and 420. Observations: In room 421, ten (10) infants were present with two (2) staff members and one (1) volunteer. One (1) infant was being held by the volunteer, two (2) were in bouncers, one (1) was in a chair, and the remaining infants were on the floor. Many of the infants were observed crawling and exploring the environment. One (1) emergency medication was stored in the cabinet. Per interview with a staff member, the child’s physician provided documentation indicating that the child was not being treated for asthma but for reactive airway disorder, using an inhaler. A parent authorization form for the inhaler was on file, dated 5/21/25. No action plan was on file. Seven (7) cribs were present in the classroom. When asked about the ten (10) infants in the room, the staff member explained that three (3) children from room 422 were combined with the group and that some cribs would be shared between two (2) children with sheet changes in between uses. A jar of baby food was stored in the refrigerator with the date it was opened clearly marked. In room 420, ten (10) children—infants and one (1)-year-olds—were present with three (3) staff members. Three (3) infants were asleep in cribs, two (2) children were in highchairs being fed, and the remaining children were on the floor with a staff member. Both children in highchairs were eating food brought from home. One (1) child was eating baby cereal from a jar, and the other child had peaches with cottage cheese. Sleep checks were logged in the Bright Wheel app. Ms. Lovelace provided the sleep log for one (1) of the children who was asleep in a crib. The children in 417 and 418 went to walk in a stroller and a buggy. In 4l6 a group of thirteen (13) children present with two (2) children. The children engaged in free play with soft blocks, toy vehicles, magnetic tiles and other materials. I observed twelve (12) children and two (2) staff members transitioned to the bathroom. Upon entering the bathroom, the staff member called each child’s name and counted. In 404, 406 and 410, both were eating and cleaning breakfast. For breakfast, sausage patties, peaches and milk were served. Items were accurately listed on the menu. In 408/409 and 414, combined classroom, the children and the staff members transitioned to the bathroom. All playgrounds were monitored. On both of the younger children’s playground, pieces of tire mulch were all over the playgrounds. Kitchen was monitored. During the visit, two (2) staff members prepared for lunch. They were making turkey/cheese wrap, sliced cucumbers, peaches and milk. All items were listed on the menu. Interaction and supervision were adequate. Fourteen (14) children’s files, one (1) new file were monitored. Eight (8) existing staff members’ were also 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 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Two (2) outlets - one (1) by the cubby and one (1) above the counter were not covered with safety outlet covers in room 414. 10A NCAC 09 .0604(c) 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 spray bottle of Goo Gone was stored in a unlocked cabinet above the sink in room 421. The warning label include "Harmful or fatal if swallowed. and keep out of reach of children". .2820(b) 847 Parent's medication authorization did not include required information. Two (2) authorization forms for diaper creams in room 417 did not have required information - parental signature and the manner in which the ointments shall be applied. In space 12, Aquaphor, assigned to a child did not include instructions for use and Desitin, assigned to a child had permission to administer forms with no parent signature. 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 an inhaler in room 421 was dated 5/21/25 and expired on 11/21/25. The inhaler was still present in the classroom. .0803(12) 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. Ziplock bags were accessible to children two (2) years of age, in room 410. .0604(q) 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. An action plan was not on file for a child who was on an inhaler for "reactive airway disorder" in room 421. .0801(b) 1898 Staff did not complete the health and safety training within one year of employment. Three (3) staff members (employment date - 11/18/24, 11/25/24 and 10/11/24) did not either complete the Health and Safety training within one (1) year of employment or maintain the certificates in their files. .1102(a) Technical assistance was provided as follows: 812: outlets All non-tampered outlets under five (5) feet must be covered with safety covers. To comply, two (2) outlets – one (1) by the cubby and one (1) above the counter must be covered with safety covers. This item was corrected during the visit. 840: Potentially hazardous products Staff members shall read the label of products. If only warning on the label include “keep out of reach of children” the products must be maintained above five (5) feet. However, if the products have additional warnings, such as “eye irritants” “harmful if swallowed”, etc. must be stored in a locked storage. To comply, please store Goo Gone spray in 421 in a locked storage. In your compliance letter, please state the action you took to meet compliance. 847: authorization form Authorization form for over-the-counter topicals and other products must include the following information. (a) the child's name; (b) the names of the authorized ointments, repellents, lotions, creams, fluoridated toothpaste, and powders; (c) the criteria for the administration of the ointments, repellents, lotions, creams, fluoridated toothpaste, and powders; (d) the manner in which the ointments, repellents, lotions, creams, fluoridated toothpaste, and powders shall be applied; (e) the signature of the parent; (f) the date the authorization was signed by the parent; and (g) the length of time the authorization is valid, if less than 12 months. To comply, authorization forms for two (2) diaper creams in 419 shall be updated. Aquaphor, assigned to child, N.C-J did not include instructions for use. In space 12, Aquaphor, assigned to child F. R. and Desitin, assigned to child B.W. had permission to administer forms with no parent signature. In your compliance letter, please verify that you obtained the information for two (2) products. 849: left over medicines and expired authorization form Authorization form is valid for up to six (6) months. The authorization form for the inhaler in 421 was signed on 5/21/25 and expired on 11/21/25. When authorization form is expired, you must return the medication within seventy-two (72) hours or obtain the new authorization form. To comply, please return the inhaler or renew the authorization form. In your compliance letter, please state the action you took to meet the compliance. 858: Easily torn plastics Easily torn plastics must be inaccessible to children under three (3). This item was corrected during the visit. 1834: Medical Action Plan Per rule listed below, any chronic conditions that require specialized health services, a medical action plan is required. Even though the child may not have asthma, he/she requires special care for reactive airway disorder. Therefore, action plan is required. The action plan can be completed by a parent or a physician. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions 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/providers/pv_provideforms.asp; To comply, either return the medication home or obtain the action plan. In your compliance letter, please state the action you took to meet the compliance. 1898: Health and Safety Training within one (1) year of employment. Medication in Child Care training is not included in CCDF and must be enrolled separately. To comply, the following staff members must complete the Health and Safety training immediately. Make sure to print the certificate upon completion and file them. B. Chalk K. Collins M. Lanning In your compliance letter, please verify that listed staff member completed the training and certificates are in their files. 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 12/18/25. 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 [email protected], 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: Lead Paint and Asbestos Testing: Your last lead water test was completed in 2021 according to the record on Clean Classroom for Carolina Kids. During the visit, Shannon Von Kaenel, Director, printed and shared a print-out of water testing completed on 6/10/25. For Lead paint and asbestos, the testing was exempt due to the year of the building, according to Ms. Lovelace. However, no records were found on the Clean Classroom website. Tire Mulch: Tire mulch around the oak tree spread all over two (2) playgrounds for younger children. Tire mulch can be chocking hazard for children. Please discuss safety protocols with your maintenance personnel. It may be possible to glue them under the tree with non-toxic glueing material. In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing was required to be completed by May 31, 2025. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is 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 [email protected] or 828.556.9013, or Bonnie Mathis, Licensing Supervisor, at [email protected]. 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