Supervision
Name of Operation: YMCA PISGAH AFTERSCHOOL Facility ID: 11000677 Consultant: KAORU EDDINS Operation Type: Center Case Number: Visit Date: 2/18/2026 Number Present: 28 Completed Date: 2/18/2026 Age: From 5 To 10 Total Minutes: 174 Time In: 01:25 PM Time Out: 04:19 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. A signed copy of the visit summary was left on-site and electronically emailed to Delaney Burke, Senior Director of Operations. I requested Ms. Burke to sign today’s visit summary and return it to me. Today, Ms. Harper was available during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-six (96) percent as of today prior to this visit. The North Carolina Secretary of State website was viewed prior to today’s visit and non-profit corporation, The Young Men’s Christian Association of Western North Carolina, Inc., is current/active as of 2/17/26. Permit type – three-star center license issued on 9/11/25. Special Services/Restrictions – daytime care, school-age only, meets enhanced space and reduced ratios. The last annual compliance visit was conducted on 3/5/25. The last fire drill was practiced on 2/16/26. The last lockdown drill was practiced on 1/21/26. The Emergency Medical Care plan was posted and current. The curriculum is Funnydaffer. Per Ms. Harper, staff members are implementing Black History Month. Lead water testing was completed on 5/6/24 without hazards. Lead paint testing was completed on 3/27/25. Site monitoring results are pending for asbestos testing. Two (2) staff members were listed on the ABCMS roster as of 2/17/26. Six (6) children from Pisgah Elementary school arrived at approximately 2:20 pm. Additional children rode DPI bus from Candler Elementary School and arrived at approximately 2:45 pm. The children were divided into two (2) groups. One (1) group remained in the gym and played basketball, and free play, such as race tracks and cars, doll house and accessories, magnetic tiles, cups, etc. The other group transitioned to cafeteria. The group stopped at the bathrooms near the cafeteria and washed their hands. Today, WOW butter, sunflower kernels, tortilla, Jelly packet, apple sauce, veggie blend juice and milk were served. The items were accurately listed on the menu. Current license, EMC, menu, emergency drill logs, Child Care Law, safe arrival/departure procedures, staff/child ratio sheet, weather chart, schedule/lesson plan were posted on the bulletin board. Playground was monitored. Since the last visit, the hole on the slide has been repaired, bars were re-painted, some of the chains for swings were replaced. No safety hazards were observed during today’s visit. Ms. Burke met with me via TEAMS and two (2) existing files were reviewed in full. No new staff members were present at this site. One (1) staff member with hire date of 8/5/24 completed CPR and First Aid training earlier today. The previous CPR/First Aid was dated 2/1/24. I explained to Ms. Burke that compliance is determined based on the expiration dates listed on the training certificates. For example, the CPR/First Aid certificate for a staff member with a hire date of 8/5/24 listed a renewal date of 02/2026. The CPR/First Aid certificate for another staff member with a hire date of 11/1/24 listed an expiration date of 3/13/27. The trainings were provided by different organizations, resulting in different expiration dates. Based on the dates indicated on the certificates, the staff member hired on 8/5/24 renewed the training by 02/2026; therefore, no violation was cited. The staff member hired on 11/1/24 must renew the training on or before 3/13/27, as indicated on the certificate. We discussed Continuous Quality Improvement (CQI). Currently, the program uses their own format to document Staff Development Plan (SDP) and CQIs are filled out upon the Rated License Assessment. We discussed that CQI and/or SDP must be monitored annually. Four (4) children’s files were also monitored via TEAMS. The program used their own version of incident logs. No medications were maintained at this facility. Supervision and interaction were positive and adequate. 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 853 Incident logs were not completed and maintained as required. YMCA program used electronic version of incident log and it was not the form provided by the Division. .0802(g)(1-6) Technical assistance was provided as follows: 853: Incident log Per rule .0802 listed below, incident log must be maintained on the form provided by the Division. To comply, you can upload the PDF version of the form and maintain them electronically, or the form must be printed and maintained at each facility. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (g) An incident log shall be completed any time an incident report is completed. This log shall: (1) include the name of the child; (2) include the date of the incident; (3) include the date the incident report was submitted to the Division, if applicable; (4) include the name of the staff member who complete the incident report; (5) be cumulative and maintained in a separate file; and (6) be available for review by a representative of the Division. This log shall be completed on a form provided by the Division. A copy of the log may be found on the Division's website at https://ncchildcare.ncdhhs.gov/Portals/0/documents/pdf/I/incident_log_i.pdf?ver=2017-05-16-105723-723. 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 3/4/26. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: [email protected] 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: We discussed that Ms. Burke was the only person who has the Legal Designee Form for this program. Therefore, today’s visit summary must be sent to Ms. Burke for signature. I also asked her to sing the Staff and Training Worksheet. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .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 [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