GS 110-91 · Violation

Name of Operation: CNT FOR CHILDREN D.C. AT KILGO UNITED METH. CHURCH Facility ID: 60000018 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 1/15/2025 Number Present: 31 Completed Date: 1/15/2025 Age: From 0 To 5 Total Minutes: 420 Time In: 11:00 AM Time Out: 06:00 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 center, I was able to enter the facility through the front door. The newly appointed administrator Ms. Cari and Ms. Satonya greeted me at the office. The center maintained a five-star rated license and continued to meet enhanced space and ratios. The Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Item Number Listing dated November 2024 were used to document compliance. Spaces #1b, 1a, 2-4, and an outdoor learning environment were monitored for compliance. No transportation for children is provided. Children were monitored, engaged in free play, tummy time, outdoor play. Thirty-two children were enrolled. Three children’s records were selected and monitored. The lesson plans posted in space 1b and 1a were not current. The date was listed as December. Children’s water bottles sent from home were monitored labeled with the child’s name but did not have the date. Space #4 was the only space with labeled and dated water bottles. There was black mold monitored on the floor next to the sink. It was recommended to contact the assigned EH inspector to the facility and discuss further. There was a cracked plexi-glass monitored in space #3. There were items monitored with small parts accessible to children under the age of three. The items were removed from the storage unit and cabinets. The center’s approved and implemented curriculum with four-year-old children was monitored implemented with Teaching Strategies. Staff and Training worksheets were in the process of being updated. Ms. Williams updated the worksheets during the visit. Four new staff files were monitored for compliance (J. Snipe, C. Morrell, C. Murphy, C. Dicker, and S. Robinson. The center’s EPR plan was monitored for compliance and current. The EPR ready to go file were monitored for compliance. It was recommended to print the EPR Ready to Go File Checklist and keep it in the ready to go file. Documentation for quarterly safety drills and monthly fire drills were discussed and monitored. We discussed documenting the pull station was used to initiate the fire alarm system, conducting at least one drill with active precipitation and tracking requirements. The daily attendance with children’s arrival and departure times were monitored documented and current for today. The outdoor learning environment was monitored for compliance. Monthly inspections were conducted and compliance issued noted and corrected. The last sanitation inspection was conducted September 24, 2024, six (6) demerits cited, and a Superior Classification issued. The last annual fire inspection was completed on June 4, 2024. It was recommended to begin the annual inspection process 4-6 weeks prior to expiration. The DCDEE annual fire inspection report must be completed by the fire inspector. Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. Posted lesson plans in space 1a and 1b were not dated. GS 110-91(12); .0508(a) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Children's water bottles sent from home were not dated. 15A NCAC 18A .2804(d) 620 All walls and ceilings including doors and windows were not kept clean, free of visible fungal growth, and in good repair. There was visible mold on the baseboards next to the sink in space #1a. 15A NCAC 18A .2825(a) 705 Equipment and furnishings were not sturdy, stable and free of hazards. Cracked plexi-glass was monitored in space #2. .0601(c) 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. Materials were monitored with small parts accessible to children under three years of age in space #4. .0604(q) Technical Assistance Provided and General Discussion: 1. It was recommended to purchase the third edition of ITERS and ECERS and begin training staff. There are several resources available on the NCRLAP website at www.NCRLAP.org. It was recommended to take advantage of the training available. 2. The preservice form for the new administrator remains required and is still needed. The church application F-1 application was emailed to the administrator in December 2024. This information will be required no later than January 22, 2025. 3. Ms. Williams to print a roster report from ABCMS. She was successful with the new process. The report was printed and reviewed. 4. It was recommended for the new administrator contact CCRI and inquire about the Director’s Leadership Academy. The new administrator was encouraged to obtain ITS-SIDS, playground safety training and EPR training. 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 Wednesday, January 29, 2025. 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

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

G.S. 110-90 · Violation

Name of Operation: CNT FOR CHILDREN D.C. AT KILGO UNITED METH. CHURCH Facility ID: 60000018 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 10/24/2024 Number Present: 31 Completed Date: 10/24/2024 Age: From 0 To 4 Total Minutes: 255 Time In: 09:45 AM Time Out: 02:00 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 for compliance with applicable child care requirements during a Routine Unannounced Visit. Upon arrival at the five-star rated licensed center, the center’s administrator was not on site and in route to the center. Ms. Satonya arrived on site shortly after the visit began. The child care item number listing dated March 2024 was used to identify and determine non-compliance. The following sections were monitored for compliance: A1, B1, C4, C5, C6, E1, E2, F3, G1, G3, G4 and G5. A walk through of spaces #1a, 1b, 2-4, and outdoor area were monitored for compliance. Children were observed eating a lunch of baked flounder, mixed squash, corn bread muffins and diced strawberries with milk. Monthly outdoor inspections, incident log, monthly fire drills and quarterly safety drills were monitored current. The center’s printed EPR plan and the Ready to Go File were monitored current. Medications were monitored with current prescriptions, medical action plan and current six-month permission slips. The previous staff and training worksheet was monitored for compliance. Two new staff were hired since the last RU visit completed in June 2024. The following new staff files were monitored for compliance: E. Taylor and K. Beachem. The following existing staff were monitored with an expired annual staff evaluation (S. Williams) and failure to renew one component of health and safety training (recognizing and responding to child maltreatment-K. Brevard). The last sanitation inspection was completed September 24, 2024, with six (6) demerits cited and a Superior classification issued. The center’s water sample was submitted Monday for lead testing, as required by EH department. We discussed possibly turning the water fountains back on and testing those fountains so each child care building can have approved drinking water in them. An email will be sent to discuss which sinks in the building could or should be tested. The last annual fire inspection was completed on June 4, 2024. It was recommended to begin your annual inspection process four to six weeks prior to expiration. 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. Three toddlers under fifteen months of age did not have a posted feeding schedule. The feeding schedules were posted during the visit .0902(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff member did not complete the recognizing and responding to child maltreatment, every five years. .1103(b) 1902 The professional development plan was not reviewed annually. One staff person did not have an annual review of the PD or staff annual evaluation. .1104 Technical Assistance Provided and General Discussion: 1. It was recommended to purchase the third edition of the ERS. It was also recommended to review all available resources at the NCRLAP website. www.NCLRAP.org. 2. It was recommended to update the staff and training worksheets and email them to the consultant by Monday. Always maintain the worksheets current. 3. We discussed the use of white noise machines in infant/toddler classrooms. Manufacturer instructions should be on file and available for review. Not more than one machine should be used at a time. The machine should be at least seven feet away from any infant. 4. We discussed adding something live to space #4. We discussed room arrangement and ERS expectation for supervision, with a modern changing table with Plexi-glass. Pictures were taken and will be shown to level one assessors next week at a fall meeting to gain clarification as to how the program would be evaluated based on the current room arrangement. 5. It was recommended to take the ABCMS’s training via the Moodle system. 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 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. 6. We discussed updating the paperwork/application for the center. The current F-1 Unincorporated paperwork is not current. The required paperwork will be emailed to Ms. Williams for the church to complete. The expectation is that the paperwork will be completed in a timely manner of no more than two weeks. We also discussed how much time a new pastor would have to complete a DCDEE CBC qualification. If the pastor should change, the new pastor would be required to obtain a DCDEE CBC qualification and letter printed, on file before the new pastor would be permitted to be inside or on the premises of either child care facility. It is a preservice requirement. 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 Thursday, November 7, 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

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0803 · Violation

Name of Operation: CNT FOR CHILDREN D.C. AT KILGO UNITED METH. CHURCH Facility ID: 60000018 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 6/6/2024 Number Present: 26 Completed Date: 6/6/2024 Age: From 0 To 4 Total Minutes: 260 Time In: 10:40 AM Time Out: 03:00 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 for applicable child care requirements during the routine unannounced visit. Michele Sullivan, Licensing Supervisor joined me today. The facility currently has a Five Star Rated License with an effective date of May 26, 2022 and continued to meet enhanced space and ratios. The facility’s 18-month compliance history before today’s visit was 87%. The facility license and NC Summary of the Child Care Law was prominently posted. Upon arrival at the center, I was buzzed in and greeted by S. Wright, infant teacher. She informed me that Ms.Satonya Williams would arrive shortly. I began the facility walkthrough and Ms. Williams joined me 15 minutes later upon arrival. Children were observed preparing for outdoor play, reading books, engaged in free play, in personal care routines, napping on mats with linen, in personal care routines. Staff interactions were nurturing and positive. The following items were monitored: supervision, staff/child ratio, first aid, CPR, special training, criminal background checks, BSAC, emergency medical care plan, administering of medication, storage of hazardous products, storage of medication, general safety, discipline, adequate/approved space, program records, license posted and permit restrictions. The Staff and Training Worksheet was reviewed to confirm staff were current with CPR, First Aid, BSAC training, and criminal background qualifying letters There was one new staff employed since the last the last Annual Compliance Visit, January 26, 2024. The new staff file (T.Tompkins) was monitored and in compliance. The last fire inspection was conducted on June 4, 2024. The last sanitation inspection was conducted on April 4, 2024, with 4 demerits and a Superior rating. The Emergency Drill Log and Report was reviewed today. The last fire drill was conducted on May 29, 2024 and the shelter-in-place drill was conducted June 5, 2024. Violation Number Comment Rule 847 Parent's medication authorization did not include required information. In Space 1a containers of sunscreens were stored with no medication authorization. In Space 2, Aquaphor diaper cream was observed without medication authorization and one diaper cream was expired. In Space 4, two diaper creams and one sunscreen were observed with no medication slip. 10A NCAC 09 .0803(4)(6-9) 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. In Space 3, diapers with open plastic wrapping were observed in an unlocked cabinet accessible to children. .0604(q) 872 Appropriate discipline practices were not followed. A toddler was observed in Space 1a standing in a crib. The teacher stated that it was not for napping purposes. The teacher was feeding a child and there were non mobile infants on the floor. Therefore the child was placed in the crib for behavior management purposes. .1803 All violations must be corrected immediately. An unannounced follow-up visit will be conducted within two weeks to verify correction and compliance with all violations. Technical Assistance Provided and General Discussion: 1.It was recommended that an area for toddler play be established in the infant room with gates or furniture allowing toddlers to play separated from infants engaged in tummy time and/or floor play. 2.We discussed implementing a system to properly obtain, complete and maintain Medical Authorization forms from parents. It was recommended that medication storage system be implemented consistently in each room. Thank you for your time today. If you have any questions, please contact Lisa Eddins-Smith at 980-748-6270 or by email at Lisa.Eddins-Smith@dhhs.nc.gov If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

G.S. 110-91 · Violation

Name of Operation: CNT FOR CHILDREN D.C. AT KILGO UNITED METH. CHURCH Facility ID: 60000018 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 1/26/2024 Number Present: 22 Completed Date: 1/29/2024 Age: From 0 To 4 Total Minutes: 420 Time In: 10:00 AM 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 center, I was greeted by the interim administrator, Ms. Santonya Williams. The center maintained a five-star rated license and continued to meet enhanced space and ratios. The Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Item Number Listing dated August 2023 were used to document compliance. Spaces #1a, 1b, 2, 3, 4 and the outdoor learning environment were monitored for compliance. The interim administrator stated the church sold the van and no longer provided transportation since COVID 19. The regulatory system was updated to reflect the current status. If transportation were desired in the future, the center would be responsible for communicating with the assigned licensing consultant prior to resuming transportation activities. Children were monitored eating their lunch, napping on mats with linen, and engaged in free play. Books were monitored in poor condition in spaces #3 and #4. We discussed clutter being stacked on top of each other on the classroom shelves and how to best combat staff storing items excessively on the shelves and possibly presenting a hazard. Current lesson plans were not posted where easily seen in spaces #3 and #4. In space #2 the center’s ITS-SIDS plan was not customized and the DCDEE sample customized policy was posted. We discussed adding children’s art work, hanging of children’s pacifiers, and how infants are taken outside for their daily outdoor time. The infant staff stated infants are taken outside by holding them in the staff’s arms or by placing them in an evacuation crib. I explained to the infant staff and Ms. Williams the evacuation cribs are only to be used in an emergency or when conducting monthly fire drills or safety drills. For daily transition to outdoor play, infants should be placed in strollers or bye-bye buggies. There were twenty-three children enrolled and twenty-two children present. Three children’s files were monitored for compliance. One child was missing a medical action plan attached to their application and in the center’s EPR RTGF. Both required applications did not have a current medical action plan attached to the child’s application. The center interim stated the Creative Curriculum with four-year-old children was the approved curriculum implemented. There are currently two, four-year-old children enrolled. It was explained to Ms. Williams that even if only 2 four-year-old children were enrolled the curriculum was expected to be implemented with the four-year-old children. Quarterly assessments, charting of children’s responses were not monitored completed or present. It was recommended to add or implement a writing center/station. Staff and Training worksheets were not current. We discussed the importance of maintaining the worksheets current at all times and the importance of maintaining the worksheets especially during a reassessment year. Ms. Williams was asked to update the worksheets and email them to me within the next two days for a final review. There were seven staff identified by Ms. Williams. There were two new hires since the last the last Routine Unannounced visit dated May 22, 2023. The two new staff files were monitored for compliance (K. Deane and E. Quarles). One existing staff file was monitored for compliance (E. Hopper). No violations were monitored in the required review of staff files. The center’s EPR plan was monitored for compliance. The current consultant’s contact information and name should be updated. The EPR RTGF was not current. Blank incident reports, an area map and children’s allergy list were not maintained in the required file. Children’s medical action plans were not attached to their application maintained in the EPR/RTGF. The RTGF checklist was emailed to Ms. Williams to help ensure all required components were maintained. Documentation for quarterly safety drills and monthly fire drills were discussed and monitored. The required safety drills were required at least once every three months. One drill was not completed at least every three months. It was recommended to plan the four required drills for the year and provide some additional days for unplanned events. The outdoor learning environment was monitored with pockets of fallen leaves in the corners and sides of rusted metal storage unit. There were approximately fourteen to twenty broken or cracked wooden fence slats. Wooden steps were monitored with an entrapment of less than greater than 3 ½ inches wide. The wooden pathway was monitored with mold or debris. The deck/pathway should be pressure washed. There were wooden picnic tables/house monitored with splinters. The metal border pegs were monitored protruding upwards beyond the black plastic borders. One side of the fence/gates was monitored not moving or dragging on the ground making the gate not close properly. Broken plastic toys were monitored on the grounds instead of being removed or made inaccessible to the children. Ms. Williams grabbed a few of the broken toys and removed them during the walk through the outdoor environment. It was suggested the church and administrator develop a consistent plan to treat the outdoor environment. The last sanitation inspection was conducted October 24, 2023, with eight (8) demerits cited, and a Superior Classification issued. The last annual fire inspection was completed June 2, 2023. It was highly recommended to begin the annual inspection process 4-6 weeks prior to expiration. Once the inspection is completed on the DCDEE Fire Inspection form, the completed inspection report should be emailed to the assigned licensing consultant within five days of receipt of the inspection report. The center continues to meet five-star requirements and a three-year reassessment will be required no later than May 26, 2025. The last ERS were completed May 10, 2022. The overall average ERS was 5.19. It was recommended to review any items scored under a 5.0 during the monthly staff meeting. Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. Two classrooms were monitored without a current activity plan. One plan was not dated at all in space#4 and in space#3 the posted plan was dated 1/2 to 1/5. GS 110-91(12); .0508(a) 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were wooden picnic tables with splinters. Border metal pegs were monitored protruding upwards. There were approximately fourteen broken wooden fence slats or portions of the fence leaning forward and not sturdy. .0601(c) 707 Equipment and furnishings not meeting the requirements outlined in child care .0601(b) and (c) were not removed or made inaccessible. Books were monitored in poor repair in space #3. .0601(d) 721 All equipment and furnishings were not in good repair. A few children's portable outdoor equipment of balls or trucks were monitored either cracked, broken or molded. All outdoor wooden borders within the children's outdoor learning environment were monitored warped, splintered or with hardware exposed. The wooden fence surrounding the outdoor learning environment was monitored with at least fourteen boards were either broken off at the top or bottom. G.S. 110-91(6); .0601(b) 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. Children's path of travel and next to the outdoor storage unit were monitored with piles of leaves. 15A NCAC 18A .2832(a) 826 Gates to the fenced outdoor play area did not remain closed while children occupied the area. One outdoor gate monitored would not open or close properly. .0605(i) 892 The center's safe sleep policy was not posted in a prominent place in the infant room where parents and caregivers were able to view daily. The posted SIDS policy was not the adopted customized policy monitored on file for infants. .0606(b) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Either drill was not completed at least once every three months in 2023. .0604(u);.0302(d)(8) 1823 The EPR Plan did not include the location of the Ready to Go File and or the required information. The center's EPR/RTGF was not current. Blank incident reports, allergy lists, children's medical action plans and area map were missing from the RTGF. .0607(d)(10) 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 child's application was monitored with a noted with a chronic medical condition but without a medical action plan attached to their application. .0801(b) Technical Assistance Provided and General Discussion: 1. The center’s not-for-profit corporation was listed as “current-active” by the NC Secretary of State’s office. 2. We discussed and reviewed the outdoor learning environment. We discussed possible trimming of trees and timelines for proper removal of fallen leaves. 3. We discussed ensuring sand, water, music, and science related activities were offered weekly. 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 Friday, February 9, 2024. 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

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

GS 110-91 · Violation

Name of Operation: CNT FOR CHILDREN D.C. AT KILGO UNITED METH. CHURCH Facility ID: 60000018 Consultant: MARA BRINTON Operation Type: Center Case Number: Visit Date: 1/26/2024 Number Present: 22 Completed Date: 1/29/2024 Age: From 0 To 4 Total Minutes: 420 Time In: 10:00 AM 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 center, I was greeted by the interim administrator, Ms. Santonya Williams. The center maintained a five-star rated license and continued to meet enhanced space and ratios. The Annual Compliance Monitoring Checklist for Child Care Centers and the Child Care Item Number Listing dated August 2023 were used to document compliance. Spaces #1a, 1b, 2, 3, 4 and the outdoor learning environment were monitored for compliance. The interim administrator stated the church sold the van and no longer provided transportation since COVID 19. The regulatory system was updated to reflect the current status. If transportation were desired in the future, the center would be responsible for communicating with the assigned licensing consultant prior to resuming transportation activities. Children were monitored eating their lunch, napping on mats with linen, and engaged in free play. Books were monitored in poor condition in spaces #3 and #4. We discussed clutter being stacked on top of each other on the classroom shelves and how to best combat staff storing items excessively on the shelves and possibly presenting a hazard. Current lesson plans were not posted where easily seen in spaces #3 and #4. In space #2 the center’s ITS-SIDS plan was not customized and the DCDEE sample customized policy was posted. We discussed adding children’s art work, hanging of children’s pacifiers, and how infants are taken outside for their daily outdoor time. The infant staff stated infants are taken outside by holding them in the staff’s arms or by placing them in an evacuation crib. I explained to the infant staff and Ms. Williams the evacuation cribs are only to be used in an emergency or when conducting monthly fire drills or safety drills. For daily transition to outdoor play, infants should be placed in strollers or bye-bye buggies. There were twenty-three children enrolled and twenty-two children present. Three children’s files were monitored for compliance. One child was missing a medical action plan attached to their application and in the center’s EPR RTGF. Both required applications did not have a current medical action plan attached to the child’s application. The center interim stated the Creative Curriculum with four-year-old children was the approved curriculum implemented. There are currently two, four-year-old children enrolled. It was explained to Ms. Williams that even if only 2 four-year-old children were enrolled the curriculum was expected to be implemented with the four-year-old children. Quarterly assessments, charting of children’s responses were not monitored completed or present. It was recommended to add or implement a writing center/station. Staff and Training worksheets were not current. We discussed the importance of maintaining the worksheets current at all times and the importance of maintaining the worksheets especially during a reassessment year. Ms. Williams was asked to update the worksheets and email them to me within the next two days for a final review. There were seven staff identified by Ms. Williams. There were two new hires since the last the last Routine Unannounced visit dated May 22, 2023. The two new staff files were monitored for compliance (K. Deane and E. Quarles). One existing staff file was monitored for compliance (E. Hopper). No violations were monitored in the required review of staff files. The center’s EPR plan was monitored for compliance. The current consultant’s contact information and name should be updated. The EPR RTGF was not current. Blank incident reports, an area map and children’s allergy list were not maintained in the required file. Children’s medical action plans were not attached to their application maintained in the EPR/RTGF. The RTGF checklist was emailed to Ms. Williams to help ensure all required components were maintained. Documentation for quarterly safety drills and monthly fire drills were discussed and monitored. The required safety drills were required at least once every three months. One drill was not completed at least every three months. It was recommended to plan the four required drills for the year and provide some additional days for unplanned events. The outdoor learning environment was monitored with pockets of fallen leaves in the corners and sides of rusted metal storage unit. There were approximately fourteen to twenty broken or cracked wooden fence slats. Wooden steps were monitored with an entrapment of less than greater than 3 ½ inches wide. The wooden pathway was monitored with mold or debris. The deck/pathway should be pressure washed. There were wooden picnic tables/house monitored with splinters. The metal border pegs were monitored protruding upwards beyond the black plastic borders. One side of the fence/gates was monitored not moving or dragging on the ground making the gate not close properly. Broken plastic toys were monitored on the grounds instead of being removed or made inaccessible to the children. Ms. Williams grabbed a few of the broken toys and removed them during the walk through the outdoor environment. It was suggested the church and administrator develop a consistent plan to treat the outdoor environment. The last sanitation inspection was conducted October 24, 2023, with eight (8) demerits cited, and a Superior Classification issued. The last annual fire inspection was completed June 2, 2023. It was highly recommended to begin the annual inspection process 4-6 weeks prior to expiration. Once the inspection is completed on the DCDEE Fire Inspection form, the completed inspection report should be emailed to the assigned licensing consultant within five days of receipt of the inspection report. The center continues to meet five-star requirements and a three-year reassessment will be required no later than May 26, 2025. The last ERS were completed May 10, 2022. The overall average ERS was 5.19. It was recommended to review any items scored under a 5.0 during the monthly staff meeting. Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. Two classrooms were monitored without a current activity plan. One plan was not dated at all in space#4 and in space#3 the posted plan was dated 1/2 to 1/5. GS 110-91(12); .0508(a) 705 Equipment and furnishings were not sturdy, stable and free of hazards. There were wooden picnic tables with splinters. Border metal pegs were monitored protruding upwards. There were approximately fourteen broken wooden fence slats or portions of the fence leaning forward and not sturdy. .0601(c) 707 Equipment and furnishings not meeting the requirements outlined in child care .0601(b) and (c) were not removed or made inaccessible. Books were monitored in poor repair in space #3. .0601(d) 721 All equipment and furnishings were not in good repair. A few children's portable outdoor equipment of balls or trucks were monitored either cracked, broken or molded. All outdoor wooden borders within the children's outdoor learning environment were monitored warped, splintered or with hardware exposed. The wooden fence surrounding the outdoor learning environment was monitored with at least fourteen boards were either broken off at the top or bottom. G.S. 110-91(6); .0601(b) 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. Children's path of travel and next to the outdoor storage unit were monitored with piles of leaves. 15A NCAC 18A .2832(a) 826 Gates to the fenced outdoor play area did not remain closed while children occupied the area. One outdoor gate monitored would not open or close properly. .0605(i) 892 The center's safe sleep policy was not posted in a prominent place in the infant room where parents and caregivers were able to view daily. The posted SIDS policy was not the adopted customized policy monitored on file for infants. .0606(b) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. Either drill was not completed at least once every three months in 2023. .0604(u);.0302(d)(8) 1823 The EPR Plan did not include the location of the Ready to Go File and or the required information. The center's EPR/RTGF was not current. Blank incident reports, allergy lists, children's medical action plans and area map were missing from the RTGF. .0607(d)(10) 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 child's application was monitored with a noted with a chronic medical condition but without a medical action plan attached to their application. .0801(b) Technical Assistance Provided and General Discussion: 1. The center’s not-for-profit corporation was listed as “current-active” by the NC Secretary of State’s office. 2. We discussed and reviewed the outdoor learning environment. We discussed possible trimming of trees and timelines for proper removal of fallen leaves. 3. We discussed ensuring sand, water, music, and science related activities were offered weekly. 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 Friday, February 9, 2024. 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