10A NCAC 09 .0304 · Violation

Name of Operation: WESTSIDE HEAD START Facility ID: 8051859 Consultant: ASHLYNN VAUGHAN Operation Type: Center Case Number: Visit Date: 5/7/2025 Number Present: 8 Completed Date: 5/7/2025 Age: From 3 To 5 Total Minutes: 100 Time In: 10:50 AM Time Out: 12:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today's visit was to monitor your program for compliance with applicable child care requirements during a Routine Unannounced visit. Your last Annual Compliance visit was conducted on December 5, 2024. Your facility’s compliance history score prior to today’s visit was 98%. You, Charleen Gillespie, Center Manager, assisted me with the visit. Your facility, owned by Salisbury-Rowan Community Action Agency Incorporated was current and active with the NC Secretary of State as viewed on the NC Secretary of State Website today. I observed your Four-Star License, NC Child Care Summary of the Law, menu, Emergency Medical Care Plan, Sanitation placard, staff-child ratio worksheets, First Aid poster, tobacco free policy signage and evacuation plans posted as required. Child to staff ratios, group size, supervision, permit restrictions, and adequate and approved space were monitored. A walk-through of the indoor and outdoor spaces was completed. I observed the children participating in free choice activities and the lunch routine. You stated that no children currently enrolled have medications or Medical Action Plans. Program records were monitored, including emergency drills, fire drills, monthly outdoor inspections, and incident logs. A sanitation inspection was conducted on April 28, 2025 with zero (0) demerits and a superior classification. A fire inspection was conducted on September 13, 2024. There has been one new staff member hired since the last visit. I monitored their file. Criminal Background Checks, CPR/First Aid, and Recognizing and Responding to Suspicions of Child Maltreatment trainings were monitored in staff files. Your signature on all forms served and will serve as verification that the information provided was accurate and complete. The following violations were observed during today’s visit. Violation Number Comment Rule 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In Space 3, one outlet was not covered by a safety plug. 10A NCAC 09 .0604(c) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. A staff member hired on 1/9/2025 did not have certification in First Aid. .1102(c) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not available for review or maintained in the staff member's file that was hired on 1/9/2025. .0608(d)(1-4) Technical Assistance: • To ensure a safe environment for children, I suggest that teachers complete a daily walkthrough of their classrooms each morning before children arrive to ensure the area is free of safety hazards, including uncovered outlets. Today the violation was corrected by placing a safety cover in the uncovered outlet. • When accepting CPR and First Aid certifications, I suggest that you utilize the "Be a Smart Consumer of First Aid and CPR Training" document found on the DCDEE website to ensure the training meets the NC child care requirements. You can access the document here: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training • Today we discussed that the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy acknowledgement statement signed and dated by the staff should include the individual’s name, the date the center’s policy was given and explained to the individual, the individual’s signature, and the date the individual signed the acknowledgment. This policy must be reviewed with new staff members prior to the individual providing care to children. Today I suggested that new staff members review and sign the policy on their first day of work. This was corrected today by having the staff member sign the policy and place the document in their file. Consultation: • NEW QRIS MODERNIZATION PLAN: The new QRIS Modernization Plan known as “Pathways to Success” is being added to law which includes moving to the use of the updated Environmental Rating Scale (ERS-3 versions) for ITERS, ECERS, and FCCERS, effective February 1, 2025. DCDEE and the NC Child Care Commission will continue the rulemaking process to add the rule language to child care requirements. This process with take several months. Hold Harmless provisions have been extended. Star rated license reassessments are postponed until the QRIS rulemaking process has been completed. Star rated license assessments are still required for new child care programs. A pathway for child care programs currently accredited through the approved accrediting bodies may now move to a 3- or 5-star license if they are not already at this star level. Providers need to submit a request to their licensing consultant and provide a copy of their accreditation award/certificate for processing: Accreditation Licensure Request Form. Please be reminded any ERS assessment completed on February 1, 2025 and after will be assessed using the ERS-3 versions. • DCDEE WEBSITE RESOURCES: -Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/. -Child Care Rules and Laws: https://ncchildcare.ncdhhs.gov/Services/Licensing/Getting-a-License -Training and Professional Development: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development -Required Health and Safety Training: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings -Care for Children Receiving Subsidy: https://ncchildcare.ncdhhs.gov/Provider/Providing-Child-Care/Subsidized-Child-Care/Care-for-Children-Receiving-Subsidy -DCDEE Updates, Current Projects, and information applicable to Child Care in NC: https://ncchildcare.ncdhhs.gov/Whats-New • ABCMS SYSTEM: The process of notifying the Division of any new child care providers working who are hired or moved into the child care facility within five business days 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 as stated in G.S. 110-90.2 & .2703(r) 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. You can access the Provider Portal Guide here: https://ncchildcare.ncdhhs.gov/Home/DCDEE-Sections/Criminal-Background-Check-Unit/Basic-Information • Child care rule 10A NCAC 09 .0304 which requires a child care center operator to: schedule and obtain a fire inspection within 12 months of the center's previous fire inspection, to notify the local fire inspector when it is time for the center's annual fire inspection, and to submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division. Child care programs are required to maintain compliance with all applicable child care rules and regulations at all times. North Carolina General Statute 110-90(4)(d) requires all child care facilities to maintain a compliance history of at least seventy-five percent (75%) for the past eighteen (18) months or during the length of time the facility has operated, whichever is less. Failure to do so may result in the issuance of a provisional license or other administrative action against the facility's license. Any violations cited during a visit may affect your score. COMPLIANCE PLAN: Violations must be corrected immediately. A signed and dated letter of compliance must be received by me no later than 5/21/2025. Your compliance documentation must include the following: • The name of your facility • The ID number of your facility • The date you write the letter • A corrective action statement for each violation stating how you corrected the violation and are now in compliance. • A compliance plan statement for each violation stating how you plan to ensure that you will not have that violation again. • Your signature Please mail or email a signed copy of the letter to: Mailing Address: P.O. Box 1078 Faith, NC 28041 Email: ashlynn.vaughan@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. If a letter is not received by the required date an unannounced follow-up visit may be conducted to confirm the violations were corrected or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education 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. Please Note: Please be aware that any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. We appreciate all you and your staff do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (704) 330-3722 or by email at ashlynn.vaughan@dhhs.nc.gov or my supervisor, Erin Pickard, at erin.pickard@dhhs.nc.gov. Thank you for your time today. 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. 110-90 · Violation

Name of Operation: WESTSIDE HEAD START Facility ID: 8051859 Consultant: ASHLYNN VAUGHAN Operation Type: Center Case Number: Visit Date: 5/7/2025 Number Present: 8 Completed Date: 5/7/2025 Age: From 3 To 5 Total Minutes: 100 Time In: 10:50 AM Time Out: 12:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today's visit was to monitor your program for compliance with applicable child care requirements during a Routine Unannounced visit. Your last Annual Compliance visit was conducted on December 5, 2024. Your facility’s compliance history score prior to today’s visit was 98%. You, Charleen Gillespie, Center Manager, assisted me with the visit. Your facility, owned by Salisbury-Rowan Community Action Agency Incorporated was current and active with the NC Secretary of State as viewed on the NC Secretary of State Website today. I observed your Four-Star License, NC Child Care Summary of the Law, menu, Emergency Medical Care Plan, Sanitation placard, staff-child ratio worksheets, First Aid poster, tobacco free policy signage and evacuation plans posted as required. Child to staff ratios, group size, supervision, permit restrictions, and adequate and approved space were monitored. A walk-through of the indoor and outdoor spaces was completed. I observed the children participating in free choice activities and the lunch routine. You stated that no children currently enrolled have medications or Medical Action Plans. Program records were monitored, including emergency drills, fire drills, monthly outdoor inspections, and incident logs. A sanitation inspection was conducted on April 28, 2025 with zero (0) demerits and a superior classification. A fire inspection was conducted on September 13, 2024. There has been one new staff member hired since the last visit. I monitored their file. Criminal Background Checks, CPR/First Aid, and Recognizing and Responding to Suspicions of Child Maltreatment trainings were monitored in staff files. Your signature on all forms served and will serve as verification that the information provided was accurate and complete. The following violations were observed during today’s visit. Violation Number Comment Rule 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In Space 3, one outlet was not covered by a safety plug. 10A NCAC 09 .0604(c) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. A staff member hired on 1/9/2025 did not have certification in First Aid. .1102(c) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not available for review or maintained in the staff member's file that was hired on 1/9/2025. .0608(d)(1-4) Technical Assistance: • To ensure a safe environment for children, I suggest that teachers complete a daily walkthrough of their classrooms each morning before children arrive to ensure the area is free of safety hazards, including uncovered outlets. Today the violation was corrected by placing a safety cover in the uncovered outlet. • When accepting CPR and First Aid certifications, I suggest that you utilize the "Be a Smart Consumer of First Aid and CPR Training" document found on the DCDEE website to ensure the training meets the NC child care requirements. You can access the document here: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training • Today we discussed that the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy acknowledgement statement signed and dated by the staff should include the individual’s name, the date the center’s policy was given and explained to the individual, the individual’s signature, and the date the individual signed the acknowledgment. This policy must be reviewed with new staff members prior to the individual providing care to children. Today I suggested that new staff members review and sign the policy on their first day of work. This was corrected today by having the staff member sign the policy and place the document in their file. Consultation: • NEW QRIS MODERNIZATION PLAN: The new QRIS Modernization Plan known as “Pathways to Success” is being added to law which includes moving to the use of the updated Environmental Rating Scale (ERS-3 versions) for ITERS, ECERS, and FCCERS, effective February 1, 2025. DCDEE and the NC Child Care Commission will continue the rulemaking process to add the rule language to child care requirements. This process with take several months. Hold Harmless provisions have been extended. Star rated license reassessments are postponed until the QRIS rulemaking process has been completed. Star rated license assessments are still required for new child care programs. A pathway for child care programs currently accredited through the approved accrediting bodies may now move to a 3- or 5-star license if they are not already at this star level. Providers need to submit a request to their licensing consultant and provide a copy of their accreditation award/certificate for processing: Accreditation Licensure Request Form. Please be reminded any ERS assessment completed on February 1, 2025 and after will be assessed using the ERS-3 versions. • DCDEE WEBSITE RESOURCES: -Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/. -Child Care Rules and Laws: https://ncchildcare.ncdhhs.gov/Services/Licensing/Getting-a-License -Training and Professional Development: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development -Required Health and Safety Training: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings -Care for Children Receiving Subsidy: https://ncchildcare.ncdhhs.gov/Provider/Providing-Child-Care/Subsidized-Child-Care/Care-for-Children-Receiving-Subsidy -DCDEE Updates, Current Projects, and information applicable to Child Care in NC: https://ncchildcare.ncdhhs.gov/Whats-New • ABCMS SYSTEM: The process of notifying the Division of any new child care providers working who are hired or moved into the child care facility within five business days 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 as stated in G.S. 110-90.2 & .2703(r) 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. You can access the Provider Portal Guide here: https://ncchildcare.ncdhhs.gov/Home/DCDEE-Sections/Criminal-Background-Check-Unit/Basic-Information • Child care rule 10A NCAC 09 .0304 which requires a child care center operator to: schedule and obtain a fire inspection within 12 months of the center's previous fire inspection, to notify the local fire inspector when it is time for the center's annual fire inspection, and to submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division. Child care programs are required to maintain compliance with all applicable child care rules and regulations at all times. North Carolina General Statute 110-90(4)(d) requires all child care facilities to maintain a compliance history of at least seventy-five percent (75%) for the past eighteen (18) months or during the length of time the facility has operated, whichever is less. Failure to do so may result in the issuance of a provisional license or other administrative action against the facility's license. Any violations cited during a visit may affect your score. COMPLIANCE PLAN: Violations must be corrected immediately. A signed and dated letter of compliance must be received by me no later than 5/21/2025. Your compliance documentation must include the following: • The name of your facility • The ID number of your facility • The date you write the letter • A corrective action statement for each violation stating how you corrected the violation and are now in compliance. • A compliance plan statement for each violation stating how you plan to ensure that you will not have that violation again. • Your signature Please mail or email a signed copy of the letter to: Mailing Address: P.O. Box 1078 Faith, NC 28041 Email: ashlynn.vaughan@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. If a letter is not received by the required date an unannounced follow-up visit may be conducted to confirm the violations were corrected or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education 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. Please Note: Please be aware that any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. We appreciate all you and your staff do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (704) 330-3722 or by email at ashlynn.vaughan@dhhs.nc.gov or my supervisor, Erin Pickard, at erin.pickard@dhhs.nc.gov. Thank you for your time today. 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.