10A NCAC 09 .0701 · Violation

Name of Operation: CONCORDIA LUTHERAN PRESCHOOL Facility ID: 18000114 Consultant: MERIA WILDER Operation Type: Center Case Number: Visit Date: 7/31/2025 Number Present: 27 Completed Date: 7/31/2025 Age: From 3 To 5 Total Minutes: 210 Time In: 09:45 AM Time Out: 01:15 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Elizabeth Murray, Director, assisted me with today’s visit. Your last annual compliance visit was conducted on September 25, 2024. I reviewed with you today the facility information found in our system. You stated there have been no changes to your phone number, mailing address, or corporate contact for the facility. You stated the email address had not changed. I reviewed the facility’s permit with you today. You stated there has been no change with the owner of your facility, Concordia Evangelical Lutheran Church. I reviewed the restrictions, capacity, and age range on your permit and observed these being maintained. Your program currently operates with a Notice of Compliance, issued on October 30, 2007. Your center's compliance history was 100% as of July 24, 2025. Your most recent fire inspection was dated August 26, 2024. Your most recent sanitation inspection was dated May 19, 2025, with a Superior classification and eight (8) demerits. Your last lead water test results dated July 24, 2024, indicated that your facility’s drinking water source was within the required limits. I verified that you had registered for the lead-based paint and asbestos testing and were determined to be exempt from this testing requirement based on the documentation provided. I completed a walk-through of the licensed indoor and outdoor spaces. Children were playing in activity areas, participating in teacher-directed whole group and small group activities, participating in routine care activities, and eating snack. A current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. Lunch was prepared by an off-site catering service or sent from home by the parent and served in the cafeteria. Snack was prepared by the preschool staff and served in the classroom. Cold food was stored in a commercial refrigerator in the school cafeteria and a full-size residential refrigerator in the staff lounge. Hot food was stored in a warming cabinet in the school cafeteria. I monitored hazardous product storage, medication storage, medication administration, general safety, and discipline. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, outdoor safety inspections, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I reviewed staff record files for two (2) returning staff members and two (2) new staff members hired since the last routine unannounced visit on March 28, 2025. Two school employees, Music Teacher and Receptionist, had expired Criminal Background Check (CBC) qualification letters. You stated the preschool children were not left alone with these individuals and their CBC qualification letters would be updated soon. I monitored a sampling of children’s record during today’s visit. I monitored health and safety requirements. I monitored supervision, staff-child ratios, group sizes, approved space use, space capacities, and permit restrictions. The “Annual Compliance Monitoring Checklist for Child Care Centers” form was completed today. No violations were observed and cited during today’s visit. Violation Number Comment Rule 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member with a hire date of 7/14/25, submitted a medical report that was dated 3/21/24 and was more than 12 months old prior to being hired. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff member with a hire date of 7/14/25, submitted a TB screening that was dated 3/21/24 and was more than 12 months old prior being hired. .0701(a) Technical Assistance: 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. * One (1) staff member with a hire date of 7/14/25, submitted a TB screening that was dated 3/21/24 and was more than 12 months old prior to being hired. TB screening/test results should dated no more than 12 months prior to the individuals date of hire. I suggest, when receiving staff paperwork during the hiring process, ensure that all documents that are being submitted by a staff member meet requirements documented in child care rule. * One (1) staff member with a hire date of 7/14/25, submitted a medical report that was dated 3/21/24 and was more than 12 months old prior to being hired. Medical Report results should dated no more than 12 months prior to the individuals date of hire. I suggest, when receiving staff paperwork during the hiring process, ensure that all documents that are being submitted by a staff member meet requirements documented in child care rule. CONSULTATION: • DCDEE 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 in 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) 814-6401 and someone will assist you. • Fire inspections are to be sent to the consultant within 7 business days of the inspection being completed. If the fire inspection report is not sent to the consultant within 7 business days a violation will be cited at the next monitoring visit • Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. • We discussed that you were working with the Criminal Background Check unit to complete the process of creating your staff roster in the ABCMS portal. You stated that you have reached out to them and had been awaiting a return phone call back, but you were going to contact them to get this completed. COMPLIANCE PLAN: Due to no violations being cited during today’s visit no compliance plan is required. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. If you have any questions, feel free to contact me by phone at (980) 434-3877 or by email at meria.wilder@dhhs.nc.gov or Licensing Supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. We appreciate all you do to serve the children and families in your community. 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: CONCORDIA LUTHERAN PRESCHOOL Facility ID: 18000114 Consultant: MERIA WILDER Operation Type: Center Case Number: Visit Date: 7/31/2025 Number Present: 27 Completed Date: 7/31/2025 Age: From 3 To 5 Total Minutes: 210 Time In: 09:45 AM Time Out: 01:15 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Elizabeth Murray, Director, assisted me with today’s visit. Your last annual compliance visit was conducted on September 25, 2024. I reviewed with you today the facility information found in our system. You stated there have been no changes to your phone number, mailing address, or corporate contact for the facility. You stated the email address had not changed. I reviewed the facility’s permit with you today. You stated there has been no change with the owner of your facility, Concordia Evangelical Lutheran Church. I reviewed the restrictions, capacity, and age range on your permit and observed these being maintained. Your program currently operates with a Notice of Compliance, issued on October 30, 2007. Your center's compliance history was 100% as of July 24, 2025. Your most recent fire inspection was dated August 26, 2024. Your most recent sanitation inspection was dated May 19, 2025, with a Superior classification and eight (8) demerits. Your last lead water test results dated July 24, 2024, indicated that your facility’s drinking water source was within the required limits. I verified that you had registered for the lead-based paint and asbestos testing and were determined to be exempt from this testing requirement based on the documentation provided. I completed a walk-through of the licensed indoor and outdoor spaces. Children were playing in activity areas, participating in teacher-directed whole group and small group activities, participating in routine care activities, and eating snack. A current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. Lunch was prepared by an off-site catering service or sent from home by the parent and served in the cafeteria. Snack was prepared by the preschool staff and served in the classroom. Cold food was stored in a commercial refrigerator in the school cafeteria and a full-size residential refrigerator in the staff lounge. Hot food was stored in a warming cabinet in the school cafeteria. I monitored hazardous product storage, medication storage, medication administration, general safety, and discipline. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, outdoor safety inspections, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I reviewed staff record files for two (2) returning staff members and two (2) new staff members hired since the last routine unannounced visit on March 28, 2025. Two school employees, Music Teacher and Receptionist, had expired Criminal Background Check (CBC) qualification letters. You stated the preschool children were not left alone with these individuals and their CBC qualification letters would be updated soon. I monitored a sampling of children’s record during today’s visit. I monitored health and safety requirements. I monitored supervision, staff-child ratios, group sizes, approved space use, space capacities, and permit restrictions. The “Annual Compliance Monitoring Checklist for Child Care Centers” form was completed today. No violations were observed and cited during today’s visit. Violation Number Comment Rule 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member with a hire date of 7/14/25, submitted a medical report that was dated 3/21/24 and was more than 12 months old prior to being hired. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff member with a hire date of 7/14/25, submitted a TB screening that was dated 3/21/24 and was more than 12 months old prior being hired. .0701(a) Technical Assistance: 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. * One (1) staff member with a hire date of 7/14/25, submitted a TB screening that was dated 3/21/24 and was more than 12 months old prior to being hired. TB screening/test results should dated no more than 12 months prior to the individuals date of hire. I suggest, when receiving staff paperwork during the hiring process, ensure that all documents that are being submitted by a staff member meet requirements documented in child care rule. * One (1) staff member with a hire date of 7/14/25, submitted a medical report that was dated 3/21/24 and was more than 12 months old prior to being hired. Medical Report results should dated no more than 12 months prior to the individuals date of hire. I suggest, when receiving staff paperwork during the hiring process, ensure that all documents that are being submitted by a staff member meet requirements documented in child care rule. CONSULTATION: • DCDEE 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 in 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) 814-6401 and someone will assist you. • Fire inspections are to be sent to the consultant within 7 business days of the inspection being completed. If the fire inspection report is not sent to the consultant within 7 business days a violation will be cited at the next monitoring visit • Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. • We discussed that you were working with the Criminal Background Check unit to complete the process of creating your staff roster in the ABCMS portal. You stated that you have reached out to them and had been awaiting a return phone call back, but you were going to contact them to get this completed. COMPLIANCE PLAN: Due to no violations being cited during today’s visit no compliance plan is required. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. If you have any questions, feel free to contact me by phone at (980) 434-3877 or by email at meria.wilder@dhhs.nc.gov or Licensing Supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. We appreciate all you do to serve the children and families in your community. 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

10A NCAC 09 .0304 · Violation

Name of Operation: CONCORDIA LUTHERAN PRESCHOOL Facility ID: 18000114 Consultant: KIMBERLY CRANE Operation Type: Center Case Number: Visit Date: 10/26/2023 Number Present: 43 Completed Date: 10/26/2023 Age: From 3 To 5 Total Minutes: 252 Time In: 09:03 AM Time Out: 01:15 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Elizabeth Murray, Administrator, assisted me with today’s visit. I conducted your last annual compliance visit on November 30, 2022. Your program currently operates with a Notice of Compliance, issued on October 30, 2007. Your program’s compliance history was 95% as of October 25, 2023 and was reviewed with you today. Your last sanitation inspection was dated September 20, 2023 with a Superior classification and 4 demerits. Your last fire inspection was dated August 9, 2023 and was received in my office on September 29, 2023. I cited a violation. I visited each licensed indoor space with you today. You stated activity plans and daily schedules were voluntarily maintained and posted online for each classroom. I observed activity areas with age-appropriate materials provided in each classroom. In Space 1, I observed children participating in a teacher directed whole group bible lesson. In Space 2, I observed children participating in a teacher-directed activity as they painted with ice cubes in small groups. I observed children also engaged in free play in activity areas. In both classrooms, I observed staff moving about the classrooms interacting with children and facilitating play and learning. I visited each licensed outdoor space with you today. I observed equipment, materials, and fences in good repair. I observed a variety of materials available to the children. I observed shade provided by the building, a covered awning, and a shade kite. I observed a new chain-linked fence installed at the street which extended the outdoor play area. You stated parents provide lunches for the children by either order through an app online from a outside vendor who prepares and delivers the meal to the school cafeteria where it is served to the child or by sending a packed lunch from home for the child. I observed nutrition opt out forms completed for each child and on file in the children’s record files. You stated the children eat lunch in the cafeteria. I observed a current snack menu posted in each classroom and on a parent information bulletin board in the hallway. You stated parents may pack a morning and afternoon snack from home and send with their child. If the parent does not provide one or both snacks, the facility provides the snacks. I observed snack prepared and served by preschool staff for the children to eat snack in the classrooms. I observed today’s morning snack included Cheez-It crackers, cheese sticks, and orange juice. I reviewed program records and staff records today. I observed and cited no violations. I reviewed children’s records today. I observed and cited one violation related to children’s records. I monitored medication storage and administration today. I observed and cited one violation related to medication administration. I observed children adequately supervised, minimum staff-child ratios and group sizes maintained, adequate approved space used, minimum space capacities maintained, and the permit restriction, “Daytime care only”, maintained during today’s visit. I completed the “Annual Compliance Monitoring Checklist for Child Care Centers” during today’s visit. I observed and cited the following violations during today's visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most fire inspection report was completed on 08/09/2023 but was not received in my office until 09/29/2023. Because the fire inspection report was received prior to today's visit, the violation was corrected. 10A NCAC 09 .0304(a) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 1, one emergency presciption medication was not stored in the original container with the pharmaceutical label attached. .0803(2)(a) 1329 Application for enrollment did not include all required information. One child application reviewed today was missing the information for any particular fears and/or unique behavior characteristics the child may have. .0801(a)(1-7) Compliance Plan: All violations cited must be corrected immediately. Please submit written, signed, and dated compliance documentation to me at the email/address below detailing the steps taken to correct each violation. Your compliance documentation must include the following: 1) A compliance letter including the following: 1. The name of your facility 2. The ID number of your facility 3. The date you write the letter 4. A corrective action statement for each violation stating how you corrected the violation and are now in compliance. 5. A compliance plan statement for each violation stating how you plan to ensure that you will not have that violation again. 6. Your signature 2) Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters, acknowledgement statements, and photographs for me to use to verify compliance. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I must receive your compliance letter no later than November 9, 2023. Please be aware 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. If you cannot meet the requirements by this date you shall contact me with a timeline of the corrections. In some cases, this timeline may be extended. 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 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. 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. Your letter may be mailed to me at: Kimberly Crane Post Office Box 6217 Hickory, NC 28603 For your convenience, your compliance letter may be sent by email to: kimberly.crane@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 in the body of the email: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 During today’s visit, I provided the following technical assistance: 1) Per child care rule 10A NCAC 09 .0304(a), the original copy of the most recently approved fire inspection report should be sent to me by email within one week of completion. Submitting the fire inspection report to me in a timely manner assists me in keeping your public record information up to date. You stated you were waiting on the sanitation inspection report so you could send them both in one email. I suggested you make it a practice to forward the email containing the fire inspection report to me when you receive it from the fire inspector. 2) Each child’s application should include information related to health care needs including any particular fears and/or unique behavior characteristics the child has. This information gives us important information we should use to provide the best possible care for the child. You stated you simply overlooked this section being left blank on the child application reviewed today. I suggested you review the child enrollment application with the parent(s) when the application is accepted to ensure all information is provided. 3) Per child care rule 10A NCAC 09 .0803(2)(a), prescription medications should be in the original pharmaceutical container with the original pharmaceutical label attached. Having the medication in the original pharmaceutical container with the original pharmaceutical label attached allows us to double-check the dosage, administration instructions, and expiration dates against the permission form to ensure accuracy. You stated you had already contacted the parent during today’s visit and requested the medication original container be brought to the facility. I suggested you review this requirement with your staff since they are often the persons that accept the medications from the parent. You requested I measure and approve the additional fenced outdoor play area. During today’s visit, I measured the additional fenced outdoor play area and named the space, “Outdoor Space 3”. I will prepare a playground diagram and outdoor space calculation sheet. Once the playground diagram and space calculation sheet are approved by my supervisor, I will send you a copy by email. As an estimated space calculation, Outdoor Space 3 has a total of 3657.03 square feet which calculates to 49 children at 75 square feet of outdoor space per child and 37 children at 100 square feet of outdoor space per child. Your facility operates under minimum space capacity requirements and would therefore be expected to provide 75 square feet of outdoor space per child. On Outdoor Space 3, you would be expected to have no more than 49 children in the space at any given time. These calculations are estimations pending my supervisor’s review and approval. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. We appreciate all you, your staff, and the church do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (828) 493-6390 or by email at kimberly.crane@dhhs.nc.gov or lead consultant and interim licensing supervisor, Erin Pickard, by email 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.

10A NCAC 09 .0803 · Violation

Name of Operation: CONCORDIA LUTHERAN PRESCHOOL Facility ID: 18000114 Consultant: KIMBERLY CRANE Operation Type: Center Case Number: Visit Date: 10/26/2023 Number Present: 43 Completed Date: 10/26/2023 Age: From 3 To 5 Total Minutes: 252 Time In: 09:03 AM Time Out: 01:15 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Elizabeth Murray, Administrator, assisted me with today’s visit. I conducted your last annual compliance visit on November 30, 2022. Your program currently operates with a Notice of Compliance, issued on October 30, 2007. Your program’s compliance history was 95% as of October 25, 2023 and was reviewed with you today. Your last sanitation inspection was dated September 20, 2023 with a Superior classification and 4 demerits. Your last fire inspection was dated August 9, 2023 and was received in my office on September 29, 2023. I cited a violation. I visited each licensed indoor space with you today. You stated activity plans and daily schedules were voluntarily maintained and posted online for each classroom. I observed activity areas with age-appropriate materials provided in each classroom. In Space 1, I observed children participating in a teacher directed whole group bible lesson. In Space 2, I observed children participating in a teacher-directed activity as they painted with ice cubes in small groups. I observed children also engaged in free play in activity areas. In both classrooms, I observed staff moving about the classrooms interacting with children and facilitating play and learning. I visited each licensed outdoor space with you today. I observed equipment, materials, and fences in good repair. I observed a variety of materials available to the children. I observed shade provided by the building, a covered awning, and a shade kite. I observed a new chain-linked fence installed at the street which extended the outdoor play area. You stated parents provide lunches for the children by either order through an app online from a outside vendor who prepares and delivers the meal to the school cafeteria where it is served to the child or by sending a packed lunch from home for the child. I observed nutrition opt out forms completed for each child and on file in the children’s record files. You stated the children eat lunch in the cafeteria. I observed a current snack menu posted in each classroom and on a parent information bulletin board in the hallway. You stated parents may pack a morning and afternoon snack from home and send with their child. If the parent does not provide one or both snacks, the facility provides the snacks. I observed snack prepared and served by preschool staff for the children to eat snack in the classrooms. I observed today’s morning snack included Cheez-It crackers, cheese sticks, and orange juice. I reviewed program records and staff records today. I observed and cited no violations. I reviewed children’s records today. I observed and cited one violation related to children’s records. I monitored medication storage and administration today. I observed and cited one violation related to medication administration. I observed children adequately supervised, minimum staff-child ratios and group sizes maintained, adequate approved space used, minimum space capacities maintained, and the permit restriction, “Daytime care only”, maintained during today’s visit. I completed the “Annual Compliance Monitoring Checklist for Child Care Centers” during today’s visit. I observed and cited the following violations during today's visit: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most fire inspection report was completed on 08/09/2023 but was not received in my office until 09/29/2023. Because the fire inspection report was received prior to today's visit, the violation was corrected. 10A NCAC 09 .0304(a) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 1, one emergency presciption medication was not stored in the original container with the pharmaceutical label attached. .0803(2)(a) 1329 Application for enrollment did not include all required information. One child application reviewed today was missing the information for any particular fears and/or unique behavior characteristics the child may have. .0801(a)(1-7) Compliance Plan: All violations cited must be corrected immediately. Please submit written, signed, and dated compliance documentation to me at the email/address below detailing the steps taken to correct each violation. Your compliance documentation must include the following: 1) A compliance letter including the following: 1. The name of your facility 2. The ID number of your facility 3. The date you write the letter 4. A corrective action statement for each violation stating how you corrected the violation and are now in compliance. 5. A compliance plan statement for each violation stating how you plan to ensure that you will not have that violation again. 6. Your signature 2) Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters, acknowledgement statements, and photographs for me to use to verify compliance. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I must receive your compliance letter no later than November 9, 2023. Please be aware 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. If you cannot meet the requirements by this date you shall contact me with a timeline of the corrections. In some cases, this timeline may be extended. 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 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. 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. Your letter may be mailed to me at: Kimberly Crane Post Office Box 6217 Hickory, NC 28603 For your convenience, your compliance letter may be sent by email to: kimberly.crane@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 in the body of the email: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 During today’s visit, I provided the following technical assistance: 1) Per child care rule 10A NCAC 09 .0304(a), the original copy of the most recently approved fire inspection report should be sent to me by email within one week of completion. Submitting the fire inspection report to me in a timely manner assists me in keeping your public record information up to date. You stated you were waiting on the sanitation inspection report so you could send them both in one email. I suggested you make it a practice to forward the email containing the fire inspection report to me when you receive it from the fire inspector. 2) Each child’s application should include information related to health care needs including any particular fears and/or unique behavior characteristics the child has. This information gives us important information we should use to provide the best possible care for the child. You stated you simply overlooked this section being left blank on the child application reviewed today. I suggested you review the child enrollment application with the parent(s) when the application is accepted to ensure all information is provided. 3) Per child care rule 10A NCAC 09 .0803(2)(a), prescription medications should be in the original pharmaceutical container with the original pharmaceutical label attached. Having the medication in the original pharmaceutical container with the original pharmaceutical label attached allows us to double-check the dosage, administration instructions, and expiration dates against the permission form to ensure accuracy. You stated you had already contacted the parent during today’s visit and requested the medication original container be brought to the facility. I suggested you review this requirement with your staff since they are often the persons that accept the medications from the parent. You requested I measure and approve the additional fenced outdoor play area. During today’s visit, I measured the additional fenced outdoor play area and named the space, “Outdoor Space 3”. I will prepare a playground diagram and outdoor space calculation sheet. Once the playground diagram and space calculation sheet are approved by my supervisor, I will send you a copy by email. As an estimated space calculation, Outdoor Space 3 has a total of 3657.03 square feet which calculates to 49 children at 75 square feet of outdoor space per child and 37 children at 100 square feet of outdoor space per child. Your facility operates under minimum space capacity requirements and would therefore be expected to provide 75 square feet of outdoor space per child. On Outdoor Space 3, you would be expected to have no more than 49 children in the space at any given time. These calculations are estimations pending my supervisor’s review and approval. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. We appreciate all you, your staff, and the church do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (828) 493-6390 or by email at kimberly.crane@dhhs.nc.gov or lead consultant and interim licensing supervisor, Erin Pickard, by email 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