Billingsville Elementary Asep

10A NCAC 09 .0803 · Violation

Name of Operation: BILLINGSVILLE ELEMENTARY ASEP Facility ID: 60003924 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 4/29/2026 Number Present: 56 Completed Date: 4/29/2026 Age: From 5 To 12 Total Minutes: 270 Time In: 02:00 PM Time Out: 06:30 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 for compliance with applicable child care requirements during the annual compliance visit. The five-star licensed afterschool program continued to operate meeting enhanced space and enhanced ratios. Upon arrival, I was sent to the school cafeteria, Ms. Michelle Broughton, PC was in the cafeteria with staff beginning to set up activity centers. A walk through of the cafeteria and outdoor learning space were monitored for compliance. The child care item listed dated April 2025 was used to determine non-compliance items. Medications were monitored for compliance. Seven children did not have a six-month permission slip on file. One child did not have a medical action plan on file. One child with two medications on file did not have the prescription maintained with the medication. The medications were maintained in a locked cabinet maintained in the cafeteria. Current allergy list was monitored and maintained in staff binders. Staff and Training worksheets were presented and monitored for compliance. One staff member did not obtain CMT training within ninety (90) days of employment. The group leader took the incorrect class. Two new staff were hired since the last AC visit completed on May 7, 2025. The following new staff files were monitored for compliance: S. Wallace and K. Shipman. One existing staff file was monitored for compliance: T. Hamm. Staff’s printed DCDEE WORKS letters were monitored. Ms. Broughton will need to log onto her WORKS profile page and apply for group leader’s qualification. Ms. Flowers will need to obtain an official transcript and apply for lead teacher and group leader evaluations. Based on the number of operating groups of children. One additional group leader will need to obtain two additional semester hours in school age coursework. An ABCMS roster report was run and verified during the visit. Sixty-three (63) children were monitored enrolled. Children attendance is maintained in staff binders. Parents were monitored signing out their children upon pick up times. DPI verification forms were monitored current and maintained in the binder. The outdoor learning environment was monitored for compliance. Monthly outdoor inspections were monitored current. Posted lesson plans and one teacher directed activity was monitored posted. It was recommended to post each staff’s CPR and FA cards on the ASEP board. Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. One child with an Epi Pen was not maintained in an original labeled container or accompanied by signed and dated written instructions form a prescribing physician or health care professional. .0803(2)(a) 847 Parent's medication authorization did not include required information. Seven children with prescribed medications for chronic medical conditions did not have a permission slip on file every six months. 10A NCAC 09 .0803(4)(6-9) 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. One child did not have a medical action plan on file for a chronic medical condition. .0801(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff member did not obtain CMT within ninety (90) days of employment. .1102(g) Technical Assistance Provided and General Discussion: 1. The Pathway to the Stars discussion was held with Ms. Broughton. The program selected Pathway #1. The program will need to be prepared to submit rated license paperwork once school returns, the first week of September. The program will need to be ready to have a SACERS-U assessment by September 2026. A center self-study will not be required for school age programs. 2. It was recommended to develop a tracking tool to assist with six month required permission slips for children’s medications. 3. 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. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted/linked on the roster. This information should be updated in ABCMS on 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) 814-8401 and someone will assist you. 4. The final summary could not be completed due to the end of the program day and continued NCID computer access issues. The handwritten summary was printed and reviewed with Ms. Broughton prior to my departure. Four (4) violations were identified and were reviewed with Ms. Broughton prior to my departure. 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. On or before May 13, 2026. 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 that any information submitted by you is considered 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. Mail or email the information to: Mara Brinton, Child Care Consultant 3687 Stallings Road Harrisburg, NC 28075 mara.brinton@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 If you have any questions or concerns, you may contact Mara Brinton at 704-594-0140 or by email at mara.brinton@dhhs.nc.gov. You may also contact my supervisor, Amy Italiano at 704-936-6065 or by email at amy.italiano@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: BILLINGSVILLE ELEMENTARY ASEP Facility ID: 60003924 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 4/29/2026 Number Present: 56 Completed Date: 4/29/2026 Age: From 5 To 12 Total Minutes: 270 Time In: 02:00 PM Time Out: 06:30 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 for compliance with applicable child care requirements during the annual compliance visit. The five-star licensed afterschool program continued to operate meeting enhanced space and enhanced ratios. Upon arrival, I was sent to the school cafeteria, Ms. Michelle Broughton, PC was in the cafeteria with staff beginning to set up activity centers. A walk through of the cafeteria and outdoor learning space were monitored for compliance. The child care item listed dated April 2025 was used to determine non-compliance items. Medications were monitored for compliance. Seven children did not have a six-month permission slip on file. One child did not have a medical action plan on file. One child with two medications on file did not have the prescription maintained with the medication. The medications were maintained in a locked cabinet maintained in the cafeteria. Current allergy list was monitored and maintained in staff binders. Staff and Training worksheets were presented and monitored for compliance. One staff member did not obtain CMT training within ninety (90) days of employment. The group leader took the incorrect class. Two new staff were hired since the last AC visit completed on May 7, 2025. The following new staff files were monitored for compliance: S. Wallace and K. Shipman. One existing staff file was monitored for compliance: T. Hamm. Staff’s printed DCDEE WORKS letters were monitored. Ms. Broughton will need to log onto her WORKS profile page and apply for group leader’s qualification. Ms. Flowers will need to obtain an official transcript and apply for lead teacher and group leader evaluations. Based on the number of operating groups of children. One additional group leader will need to obtain two additional semester hours in school age coursework. An ABCMS roster report was run and verified during the visit. Sixty-three (63) children were monitored enrolled. Children attendance is maintained in staff binders. Parents were monitored signing out their children upon pick up times. DPI verification forms were monitored current and maintained in the binder. The outdoor learning environment was monitored for compliance. Monthly outdoor inspections were monitored current. Posted lesson plans and one teacher directed activity was monitored posted. It was recommended to post each staff’s CPR and FA cards on the ASEP board. Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. One child with an Epi Pen was not maintained in an original labeled container or accompanied by signed and dated written instructions form a prescribing physician or health care professional. .0803(2)(a) 847 Parent's medication authorization did not include required information. Seven children with prescribed medications for chronic medical conditions did not have a permission slip on file every six months. 10A NCAC 09 .0803(4)(6-9) 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. One child did not have a medical action plan on file for a chronic medical condition. .0801(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff member did not obtain CMT within ninety (90) days of employment. .1102(g) Technical Assistance Provided and General Discussion: 1. The Pathway to the Stars discussion was held with Ms. Broughton. The program selected Pathway #1. The program will need to be prepared to submit rated license paperwork once school returns, the first week of September. The program will need to be ready to have a SACERS-U assessment by September 2026. A center self-study will not be required for school age programs. 2. It was recommended to develop a tracking tool to assist with six month required permission slips for children’s medications. 3. 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. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted/linked on the roster. This information should be updated in ABCMS on 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) 814-8401 and someone will assist you. 4. The final summary could not be completed due to the end of the program day and continued NCID computer access issues. The handwritten summary was printed and reviewed with Ms. Broughton prior to my departure. Four (4) violations were identified and were reviewed with Ms. Broughton prior to my departure. 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. On or before May 13, 2026. 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 that any information submitted by you is considered 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. Mail or email the information to: Mara Brinton, Child Care Consultant 3687 Stallings Road Harrisburg, NC 28075 mara.brinton@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 If you have any questions or concerns, you may contact Mara Brinton at 704-594-0140 or by email at mara.brinton@dhhs.nc.gov. You may also contact my supervisor, Amy Italiano at 704-936-6065 or by email at amy.italiano@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: BILLINGSVILLE ELEMENTARY ASEP Facility ID: 60003924 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 4/29/2026 Number Present: 56 Completed Date: 4/29/2026 Age: From 5 To 12 Total Minutes: 270 Time In: 02:00 PM Time Out: 06:30 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 for compliance with applicable child care requirements during the annual compliance visit. The five-star licensed afterschool program continued to operate meeting enhanced space and enhanced ratios. Upon arrival, I was sent to the school cafeteria, Ms. Michelle Broughton, PC was in the cafeteria with staff beginning to set up activity centers. A walk through of the cafeteria and outdoor learning space were monitored for compliance. The child care item listed dated April 2025 was used to determine non-compliance items. Medications were monitored for compliance. Seven children did not have a six-month permission slip on file. One child did not have a medical action plan on file. One child with two medications on file did not have the prescription maintained with the medication. The medications were maintained in a locked cabinet maintained in the cafeteria. Current allergy list was monitored and maintained in staff binders. Staff and Training worksheets were presented and monitored for compliance. One staff member did not obtain CMT training within ninety (90) days of employment. The group leader took the incorrect class. Two new staff were hired since the last AC visit completed on May 7, 2025. The following new staff files were monitored for compliance: S. Wallace and K. Shipman. One existing staff file was monitored for compliance: T. Hamm. Staff’s printed DCDEE WORKS letters were monitored. Ms. Broughton will need to log onto her WORKS profile page and apply for group leader’s qualification. Ms. Flowers will need to obtain an official transcript and apply for lead teacher and group leader evaluations. Based on the number of operating groups of children. One additional group leader will need to obtain two additional semester hours in school age coursework. An ABCMS roster report was run and verified during the visit. Sixty-three (63) children were monitored enrolled. Children attendance is maintained in staff binders. Parents were monitored signing out their children upon pick up times. DPI verification forms were monitored current and maintained in the binder. The outdoor learning environment was monitored for compliance. Monthly outdoor inspections were monitored current. Posted lesson plans and one teacher directed activity was monitored posted. It was recommended to post each staff’s CPR and FA cards on the ASEP board. Violation Number Comment Rule 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. One child with an Epi Pen was not maintained in an original labeled container or accompanied by signed and dated written instructions form a prescribing physician or health care professional. .0803(2)(a) 847 Parent's medication authorization did not include required information. Seven children with prescribed medications for chronic medical conditions did not have a permission slip on file every six months. 10A NCAC 09 .0803(4)(6-9) 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. One child did not have a medical action plan on file for a chronic medical condition. .0801(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff member did not obtain CMT within ninety (90) days of employment. .1102(g) Technical Assistance Provided and General Discussion: 1. The Pathway to the Stars discussion was held with Ms. Broughton. The program selected Pathway #1. The program will need to be prepared to submit rated license paperwork once school returns, the first week of September. The program will need to be ready to have a SACERS-U assessment by September 2026. A center self-study will not be required for school age programs. 2. It was recommended to develop a tracking tool to assist with six month required permission slips for children’s medications. 3. 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. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted/linked on the roster. This information should be updated in ABCMS on 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) 814-8401 and someone will assist you. 4. The final summary could not be completed due to the end of the program day and continued NCID computer access issues. The handwritten summary was printed and reviewed with Ms. Broughton prior to my departure. Four (4) violations were identified and were reviewed with Ms. Broughton prior to my departure. 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. On or before May 13, 2026. 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 that any information submitted by you is considered 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. Mail or email the information to: Mara Brinton, Child Care Consultant 3687 Stallings Road Harrisburg, NC 28075 mara.brinton@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 If you have any questions or concerns, you may contact Mara Brinton at 704-594-0140 or by email at mara.brinton@dhhs.nc.gov. You may also contact my supervisor, Amy Italiano at 704-936-6065 or by email at amy.italiano@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: BILLINGSVILLE ELEMENTARY ASEP Facility ID: 60003924 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 30 Completed Date: 8/28/2024 Age: From 5 To 8 Total Minutes: 160 Time In: 02:20 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor for compliance with applicable child care requirements during the Annual Compliance Visit. Upon arrival at the CMS DPI licensed five star rated afterschool program, the PC was on site and preparing to receive children. It was the second day of school and Ms. Broughton, PC, was not happy the annual compliance was being conducted. We discussed conducting two AC visits in the year to change the AC month for the facility. An AC would be completed in the spring of 2025 sometime as well as a Routine Unannounced visit. Due to connectivity issues related to the DCDEE VPN, the visit summary could not be finalized. A final visit summary will be completed and emailed within the next twenty-four (24) hours. The center maintained a five-star rated license and continues to meet enhanced space and ratios and the highest voluntary enhanced ratios. The Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Item Number Listing dated March 2024 were used to document compliance. Spaces #E1-E2, cafeteria and one outdoor learning environment were monitored for compliance. No transportation is provided for the program children. Children were monitored, hand washing, eating PM snack, and engaged in free play. The process of receiving children when the day school dismisses was observed. We discussed placement of the required posted items in the cafeteria when the primary space for children were #E1 and #E2. Parents pick up their children from the door in space #E1 at the end of the program day. A discussion will be held with the licensing supervisor based on a previous discussion held regarding the topic during the RU visit completed in June of 2024. Based on the licensing intent of why certain documents are required to be posted is for parents’ information. If the required documents are not accessible/posted where parents can see them, then I am not sure of the current board’s location meets the intent of the child care rules. There were unused electrical sockets in space E2 and the hallway directly outside of the bathroom the program children used. While the bulletin board in the cafeteria was monitored and children arrived at the cafeteria to obtain their PM snack a power tool was monitored opened and stored in the back corner of the cafeteria. Power tools must be stored under lock and key. Three children’s files were monitored for compliance and found to meet child care requirements. Staff and Training worksheets were emailed to me prior to the visit. There were not any new staff hired since the last Routine Unannounced visit was completed on June 5, 2024. The ASEP Program Assistant, Ms. Good, arrived as children began being placed by Ms. Broughton. Had Ms. Good not arrived at the time she did, the center would have been out of required staff to child ratio. Two existing staff files were monitored for compliance based on the number of staff working during the summer. An annual review of the CMS site specific Risk Management Tool was not current. Ms. Broughton stated the new assistant principal is still in the process of revising the plan. However, the most current or existing plan was not reviewed annually with staff. I informed Ms. Broughton to take the most current plan and review it with all staff until the revision process is completed by the assistant principal. The center’s emergency medical care plan was not current or reviewed annually with staff. Documentation for quarterly safety drills and monthly fire drills were monitored documented and current. The outdoor learning environment was monitored for compliance. The last sanitation inspection was conducted April 17, 2024, with two (2) demerits cited, and a Superior Classification issued. The last annual fire inspection was completed on February 2, 2024. It was highly recommended to meet with the school administration to determine who in the school is responsible for the two fire inspections that occur in a year. The school staff must be made aware that any time a fire inspection occurs, the inspection report issued must be given to the PC (Ms. Broughton) so she may email the fire inspection to the assigned state licensing consultant. Upon receipt of the inspection, by child care rule, the provider has seven days to submit the inspection report to the assigned licensing consultant. Violation Number Comment Rule 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A power tool (floor cleaner) was stored in the cafeteria, accessible to children. .0604(a) 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. There were unused electrical outlets not covered or made inaccessible to children in the hallway directly outside of the children's restrooms and in space E2. 10A NCAC 09 .0604(c) 832 There was no written emergency medical care (EMC) plan. The center's EMC plan was not current or annually reviewed with current staff. 10A NCAC 09 .0802(a) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. CMS site specific Risk Management plan was not reviewed annually with all staff. .0607(e) Technical Assistance Provided and General Discussion: 1. Ms. Broughton was asked to update the staff and training worksheets and store them electronically to help with reviewing and editing information required to be maintained or available for review. 2. It was the second day of school, and the programmatic spaces were not fully set up. 3. There was a concern expressed about whether there were adequate staff to maintain the required staff to child ratios. Based on reviewing the ages of the enrolled children, if every child arrives for afterschool, the center does not have enough staff to maintain the required ratios. The program assistant, Ms. Good arrived just in time, so a violation was not cited. The concern is what will happen in the future if Ms. Good doesn’t arrive on time or if she is required to go to another program because a licensing consultant arrived. Corrective Action Plan: All violations must be corrected immediately. You shall submit a written, signed, and dated statement/compliance letter to me, at the address below detailing how each violation has been corrected and when. This information shall be received by Tuesday, September 10, 2024. You may email me your letter of correction. Mail written documentation to Mara Brinton, 7870 Woodmere Drive, Harrisburg, NC 28075. 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 or an administrative action may be recommended. 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. If you have any questions, please contact Mara Brinton at 704-594-0140 or email mara.brinton@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 .0802 · Violation

Name of Operation: BILLINGSVILLE ELEMENTARY ASEP Facility ID: 60003924 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 30 Completed Date: 8/28/2024 Age: From 5 To 8 Total Minutes: 160 Time In: 02:20 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor for compliance with applicable child care requirements during the Annual Compliance Visit. Upon arrival at the CMS DPI licensed five star rated afterschool program, the PC was on site and preparing to receive children. It was the second day of school and Ms. Broughton, PC, was not happy the annual compliance was being conducted. We discussed conducting two AC visits in the year to change the AC month for the facility. An AC would be completed in the spring of 2025 sometime as well as a Routine Unannounced visit. Due to connectivity issues related to the DCDEE VPN, the visit summary could not be finalized. A final visit summary will be completed and emailed within the next twenty-four (24) hours. The center maintained a five-star rated license and continues to meet enhanced space and ratios and the highest voluntary enhanced ratios. The Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Item Number Listing dated March 2024 were used to document compliance. Spaces #E1-E2, cafeteria and one outdoor learning environment were monitored for compliance. No transportation is provided for the program children. Children were monitored, hand washing, eating PM snack, and engaged in free play. The process of receiving children when the day school dismisses was observed. We discussed placement of the required posted items in the cafeteria when the primary space for children were #E1 and #E2. Parents pick up their children from the door in space #E1 at the end of the program day. A discussion will be held with the licensing supervisor based on a previous discussion held regarding the topic during the RU visit completed in June of 2024. Based on the licensing intent of why certain documents are required to be posted is for parents’ information. If the required documents are not accessible/posted where parents can see them, then I am not sure of the current board’s location meets the intent of the child care rules. There were unused electrical sockets in space E2 and the hallway directly outside of the bathroom the program children used. While the bulletin board in the cafeteria was monitored and children arrived at the cafeteria to obtain their PM snack a power tool was monitored opened and stored in the back corner of the cafeteria. Power tools must be stored under lock and key. Three children’s files were monitored for compliance and found to meet child care requirements. Staff and Training worksheets were emailed to me prior to the visit. There were not any new staff hired since the last Routine Unannounced visit was completed on June 5, 2024. The ASEP Program Assistant, Ms. Good, arrived as children began being placed by Ms. Broughton. Had Ms. Good not arrived at the time she did, the center would have been out of required staff to child ratio. Two existing staff files were monitored for compliance based on the number of staff working during the summer. An annual review of the CMS site specific Risk Management Tool was not current. Ms. Broughton stated the new assistant principal is still in the process of revising the plan. However, the most current or existing plan was not reviewed annually with staff. I informed Ms. Broughton to take the most current plan and review it with all staff until the revision process is completed by the assistant principal. The center’s emergency medical care plan was not current or reviewed annually with staff. Documentation for quarterly safety drills and monthly fire drills were monitored documented and current. The outdoor learning environment was monitored for compliance. The last sanitation inspection was conducted April 17, 2024, with two (2) demerits cited, and a Superior Classification issued. The last annual fire inspection was completed on February 2, 2024. It was highly recommended to meet with the school administration to determine who in the school is responsible for the two fire inspections that occur in a year. The school staff must be made aware that any time a fire inspection occurs, the inspection report issued must be given to the PC (Ms. Broughton) so she may email the fire inspection to the assigned state licensing consultant. Upon receipt of the inspection, by child care rule, the provider has seven days to submit the inspection report to the assigned licensing consultant. Violation Number Comment Rule 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A power tool (floor cleaner) was stored in the cafeteria, accessible to children. .0604(a) 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. There were unused electrical outlets not covered or made inaccessible to children in the hallway directly outside of the children's restrooms and in space E2. 10A NCAC 09 .0604(c) 832 There was no written emergency medical care (EMC) plan. The center's EMC plan was not current or annually reviewed with current staff. 10A NCAC 09 .0802(a) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. CMS site specific Risk Management plan was not reviewed annually with all staff. .0607(e) Technical Assistance Provided and General Discussion: 1. Ms. Broughton was asked to update the staff and training worksheets and store them electronically to help with reviewing and editing information required to be maintained or available for review. 2. It was the second day of school, and the programmatic spaces were not fully set up. 3. There was a concern expressed about whether there were adequate staff to maintain the required staff to child ratios. Based on reviewing the ages of the enrolled children, if every child arrives for afterschool, the center does not have enough staff to maintain the required ratios. The program assistant, Ms. Good arrived just in time, so a violation was not cited. The concern is what will happen in the future if Ms. Good doesn’t arrive on time or if she is required to go to another program because a licensing consultant arrived. Corrective Action Plan: All violations must be corrected immediately. You shall submit a written, signed, and dated statement/compliance letter to me, at the address below detailing how each violation has been corrected and when. This information shall be received by Tuesday, September 10, 2024. You may email me your letter of correction. Mail written documentation to Mara Brinton, 7870 Woodmere Drive, Harrisburg, NC 28075. 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 or an administrative action may be recommended. 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. If you have any questions, please contact Mara Brinton at 704-594-0140 or email mara.brinton@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