NC GS 110-90 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: 1225-162L Visit Date: 12/18/2025 Number Present: 81 Completed Date: 12/19/2025 Age: From 0 To 5 Total Minutes: 75 Time In: 12:45 PM Time Out: 02:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to investigate a report that was received alleging non-compliance of child care requirements. Lynn Lee, Director, was present and assisted me during the visit. The visit summary was completed off-site, emailed, and reviewed with Ms. Lee by telephone. Upon arrival, I was greeted by the assistant director, Dana Hall. I completed a general walk through of six (6) classrooms with Ms. Lee. There were ten (10) staff, and eighty-one (81) children present on the visit today. Children throughout the facility were observed down for nap. Some children who were not asleep were resting quietly on their cots. Limited monitoring of child care requirements was conducted during the visit. The Notice of Compliance and emergency care plan were posted. During today’s visit, I discussed the allegation with the director and six staff. They were given an opportunity to provide information surrounding the allegation. ALLEGATION There are concerns about the mental stability of staff. FINDINGS During the interviews, I asked if there had been any concern about staff making inappropriate comments or exhibiting unusual behaviors in the presence of children. Staff reported no awareness of anyone making inappropriate comments in the presence of children and expressed no concerns regarding unusual staff behavior. The staff indicated that the director or assistant director would be notified if any such behavior was observed. The information received was consistent across all responses. A review of staff medical reports indicated no emotional or physical limitations that would interfere with child care responsibilities. The following violation was observed, documented and technical assistance regarding maintaining compliance was offered. The violation was not related to the allegation. Violation Number Comment Rule 614 Bed, cribs, playpens, cots or mats were not placed at least 18" apart or separated by partitions when in use. The cots in space #5E were not 18" apart or separated by partitions during nap. 15A NCAC 18A .2821(e) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A letter of compliance must be sent to me by January 1, 2026. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number Your compliance history prior to today’s visit was 92%. Child care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. TECHNICAL ASSISTANCE The children’s mats should not touch. Use low shelves or approved dividers if 18 inches isn't possible, ensuring caregivers can still see and access children easily. INVESTIGATION STATUS The case will remain open for further investigation. A return visit will be made in the near future. If I can be of any assistance or if you have any questions, please feel free to contact me at (919) 819-9378 or by email at Kia.Reid@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.

10A NCAC 09 .0701 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: Visit Date: 10/27/2025 Number Present: 77 Completed Date: 10/27/2025 Age: From 2 To 5 Total Minutes: 180 Time In: 10:00 AM Time Out: 01:00 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 child care requirements during your routine unannounced visit. The visit summary was reviewed with the director, Lynn Lee, and a copy was given to her at the conclusion of the visit today. Upon arrival, I was greeted by the assistant director, Dana Hall. I completed a general walk-through of the indoor and outdoor areas with Ms. Lee. Children throughout the facility were participating in personal care routines, completing fall related art projects, in center activities, and outdoor play. LICENSE STATUS Currently this center operates with a Notice of Compliance issued December 10, 2024. INSPECTIONS *The last annual compliance visit was conducted on April 17, 2025. *The sanitation inspection was completed on October 23, 2025, with a "Superior" classification. *The last fire inspection was completed on December 13, 2024. *The last documented fire drill was completed on October 13, 2025. *The last documented playground inspection was completed on October 8, 2025. *The last documented lockdown drill was conducted on September 12, 2025. During this visit, a partial assessment of Child Care Requirements was conducted monitoring all classrooms. The monitoring included License and Permit Restrictions, Staff/Child Ratios, Supervision, CPR/First Aid coverage for the center, Special Training Requirements, Storage of Hazardous Items and Medication, Use of Approved Space, Criminal Background Checks, Program Records and Materials/Equipment for the Indoor Environment. The following violations were observed, documented and technical assistance regarding maintaining compliance was offered. 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. Two staff who both started employment on 6/2/25 did not have medical reports on file. 10A NCAC 09 .0701(a) 1757 A valid qualification letter was not on file and available to review at the facility. The qualification letter for one staff expired on 8/31/25. G.S. 110-90.2(b) & (d) & .2703(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Three staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training. .1102(g) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A compliance letter must be sent to me by November 10, 2025. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number TECHNICAL ASSISTANCE Th qualification letter for J. Reaves expired on 8/31/25. I explained to the director that the employee has until 11/10/25 to complete the CBC process and obtain a new qualifying letter. I stated that if a new qualifying letter is not submitted to me by 11/10/25, a return visit will be made to the facility. At that time, I will re-cite the violation, and the employee must leave the facility until a new qualification letter is obtained and available for my review. *The qualification letters for will expire soon for the following staff. C. Hargrove 10/28/25 (Paperwork has been submitted on 10/16/25 and is pending in the ABCMS portal.) D. Hall will expire on 12/4/25 T. Clayton 1/7/26 Remember your paperwork for the 5-year re-check can be submitted SIX months prior to the expiration of the qualification letter. -A checklist should be created to keep track of the expiration dates for all required trainings. Each file should contain a staff file checklist to ensure all paperwork is submitted/completed by the due date listed on the checklist. The staff file checklist can be found under the providers tab on the DCDEE website. STAFF RECORDS I monitored two new staff files since the last annual compliance visit on 5/1/24 for criminal background qualifying letters, current CPR/First Aid, medical, TB test and other specialized training. CHILD CARE RULES Child Care Rules have been updated as of 7/1/25. Please visit the DCDEE website to review and download a copy. The following free trainings are available on the Moodle portal. -Child Development module -Summary of Rule Changes Effective July 1, 2025 (Pathways to the Stars Rule Rollout) Automated Background Check Monitoring System North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: •See the real-time background check status of staff members. •Run a printable report of the staff roster to assist with compliance visits. •See new background check applicants and add to staff roster. To get started, complete the ABCMS Child Care Provider Portal Training in Moodle—a video tutorial followed by a few questions. REMINDERS The following requirements will come due in the near future; please make arrangements to complete the items before the deadline. *You must obtain a fire inspection by 12/13/25. The facility must obtain a fire inspection within twelve months of the previous inspection as per Child Care Rule .0304(a). *Please check the Division of Child Development and Early Education website: ncchildcare.ncdhhs.gov frequently and click the “what’s new” tab to stay informed of all updates available to you. If you have any questions or if I can be of any assistance, please feel free to contact me at (919) 819-9378. 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: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: Visit Date: 10/27/2025 Number Present: 77 Completed Date: 10/27/2025 Age: From 2 To 5 Total Minutes: 180 Time In: 10:00 AM Time Out: 01:00 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 child care requirements during your routine unannounced visit. The visit summary was reviewed with the director, Lynn Lee, and a copy was given to her at the conclusion of the visit today. Upon arrival, I was greeted by the assistant director, Dana Hall. I completed a general walk-through of the indoor and outdoor areas with Ms. Lee. Children throughout the facility were participating in personal care routines, completing fall related art projects, in center activities, and outdoor play. LICENSE STATUS Currently this center operates with a Notice of Compliance issued December 10, 2024. INSPECTIONS *The last annual compliance visit was conducted on April 17, 2025. *The sanitation inspection was completed on October 23, 2025, with a "Superior" classification. *The last fire inspection was completed on December 13, 2024. *The last documented fire drill was completed on October 13, 2025. *The last documented playground inspection was completed on October 8, 2025. *The last documented lockdown drill was conducted on September 12, 2025. During this visit, a partial assessment of Child Care Requirements was conducted monitoring all classrooms. The monitoring included License and Permit Restrictions, Staff/Child Ratios, Supervision, CPR/First Aid coverage for the center, Special Training Requirements, Storage of Hazardous Items and Medication, Use of Approved Space, Criminal Background Checks, Program Records and Materials/Equipment for the Indoor Environment. The following violations were observed, documented and technical assistance regarding maintaining compliance was offered. 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. Two staff who both started employment on 6/2/25 did not have medical reports on file. 10A NCAC 09 .0701(a) 1757 A valid qualification letter was not on file and available to review at the facility. The qualification letter for one staff expired on 8/31/25. G.S. 110-90.2(b) & (d) & .2703(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Three staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training. .1102(g) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A compliance letter must be sent to me by November 10, 2025. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number TECHNICAL ASSISTANCE Th qualification letter for J. Reaves expired on 8/31/25. I explained to the director that the employee has until 11/10/25 to complete the CBC process and obtain a new qualifying letter. I stated that if a new qualifying letter is not submitted to me by 11/10/25, a return visit will be made to the facility. At that time, I will re-cite the violation, and the employee must leave the facility until a new qualification letter is obtained and available for my review. *The qualification letters for will expire soon for the following staff. C. Hargrove 10/28/25 (Paperwork has been submitted on 10/16/25 and is pending in the ABCMS portal.) D. Hall will expire on 12/4/25 T. Clayton 1/7/26 Remember your paperwork for the 5-year re-check can be submitted SIX months prior to the expiration of the qualification letter. -A checklist should be created to keep track of the expiration dates for all required trainings. Each file should contain a staff file checklist to ensure all paperwork is submitted/completed by the due date listed on the checklist. The staff file checklist can be found under the providers tab on the DCDEE website. STAFF RECORDS I monitored two new staff files since the last annual compliance visit on 5/1/24 for criminal background qualifying letters, current CPR/First Aid, medical, TB test and other specialized training. CHILD CARE RULES Child Care Rules have been updated as of 7/1/25. Please visit the DCDEE website to review and download a copy. The following free trainings are available on the Moodle portal. -Child Development module -Summary of Rule Changes Effective July 1, 2025 (Pathways to the Stars Rule Rollout) Automated Background Check Monitoring System North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: •See the real-time background check status of staff members. •Run a printable report of the staff roster to assist with compliance visits. •See new background check applicants and add to staff roster. To get started, complete the ABCMS Child Care Provider Portal Training in Moodle—a video tutorial followed by a few questions. REMINDERS The following requirements will come due in the near future; please make arrangements to complete the items before the deadline. *You must obtain a fire inspection by 12/13/25. The facility must obtain a fire inspection within twelve months of the previous inspection as per Child Care Rule .0304(a). *Please check the Division of Child Development and Early Education website: ncchildcare.ncdhhs.gov frequently and click the “what’s new” tab to stay informed of all updates available to you. If you have any questions or if I can be of any assistance, please feel free to contact me at (919) 819-9378. 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 .0302 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: Visit Date: 4/17/2025 Number Present: 80 Completed Date: 4/17/2025 Age: From 2 To 5 Total Minutes: 195 Time In: 10:00 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 unannounced visit was to monitor child care requirements during your annual compliance visit. The visit summary was reviewed with the director, Lynn Lee, and a copy was given to her at the conclusion of the visit. Upon arrival, I was greeted by Ms. Lee. We completed a general walk through of the indoor and outdoor areas. Children throughout the facility were participating in personal care routines, free play of indoor areas, outdoor play, and eating lunch. LICENSE STATUS Currently this center operates with a Notice of Compliance issued December 10, 2014. INSPECTIONS *The last annual compliance visit was conducted on May 1, 2024. *The sanitation inspection was completed on December 16, 2024, with a "Superior" classification. *The last fire inspection was completed on December 13, 2024, and the facility is approved for day time care only. *The last documented fire drill was completed on April 14, 2025. *The last documented playground inspection was completed on March 18, 2025. *The last documented lockdown drill was conducted on February 6, 2025. Prior to today's visit I reviewed the NC Secretary of State's website and observed that the owner of this facility, Mt. Sylvan United Methodist Church is listed as current/active. During this visit, a full assessment of Child Care Requirements was conducted. A checklist was used to note the requirements monitored today. The following violations were observed, documented and technical assistance regarding maintaining compliance was offered. Violation Number Comment Rule 125 Daily records of arrival and departure times for children at the center were not maintained as children arrive and depart and/or were not made available for review. The attendance records did not include the arrival and departure times for the children. 10A NCAC 09 .0302(d)(4) 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 A the children's extra clothing was stored in ziploc bags in the children's cubbies. In space F a plastic bag with extra clothing was hanging on a hook and a plastic bag with toilet paper rolls was in an unlocked cabinet. All of these items were within reach of the children under three years of age. .0604(q) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A compliance letter must be sent to me by May 1, 2025. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number COMPLIANCE HISTORY Prior to today's visit, the Compliance History Score for the center was 86%. According to NC General Statute 110-90 (4)(d) all facilities must maintain a compliance history of at least seventy-five percent (75%) for the past 18 months. TECHNICAL ASSISTANCE *All attendance records must include arrival and departure times. If the parents do not document this information the classroom staff must complete the form. *The staff in each classroom should conduct a walk-through of the children’s space prior to them arriving each day, removing any potential hazards and placing them at least five feet high or kept in locked storage. Safety is a priority when caring for young children. ANNUAL COMPLIANCE RECORDS Nine children’s records were reviewed. Staff and training worksheets were monitored for new staff and two (2) existing staff. The director’s signature attests that staff files not monitored today contain all the required information. CONSULTATION Upon reviewing the regulatory database containing owner information I found information listed for the previous pastor. I informed Ms. Lee that I would need a letter stating who the new facility contact person will be so the information can be updated in the regulatory system. REMINDERS The following requirements will come due in the near future; please make arrangements to complete the items before the deadline. *The qualification letter expiration dates are listed below for the following staff. K. Biting 8/25/25 J. Hodges 8/31/25 C. Hargrove 10/28/25 C. Hill 10/28/25 D. Deaton 12/4/25 Remember your paperwork for the 5-year re-check can be submitted six months prior to the expiration of the qualification letter. *Please check the Division of Child Development and Early Education website: ncchildcare.ncdhhs.gov frequently and click the “what’s new” tab to stay informed of all updates available to you. If you have any questions or if I can be of any assistance, please feel free to contact me at (919) 819-9378. 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.

10A NCAC 09 .0601 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: 1124-216L Visit Date: 12/5/2024 Number Present: 79 Completed Date: 12/5/2024 Age: From 2 To 5 Total Minutes: 120 Time In: 09:30 AM Time Out: 11:30 AM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to investigate a report that was received November 20, 2024, alleging non-compliance of child care requirements. Lynn Lee, Director, was present and assisted me during the visit. The visit summary was completed off-site, emailed, and reviewed with Ms. Lee by telephone. Upon arrival, I was greeted by, the assistant director, Dana Hall. I completed a general walk through of six (6) classrooms with Ms. Lee. There were twelve (12) staff, and seventy-nine (79) children present on the visit today. The children were observed in routine care, circle time, center and outdoor activities. Limited monitoring of child care requirements was conducted during the visit. Supervision of children, staff/child ratios, general safety, use of adequate/approved space, and permit restrictions were monitored. The Notice of Compliance and emergency care plan were posted. During today’s visit, I discussed the allegations with the director and two staff. They were given an opportunity to provide information surrounding the allegations. ALLEGATION #1 There are concerns regarding supervision. FINDINGS I asked the director if she had any concerns from parents or staff concerning supervision. She stated the only thing she could think of was that a staff member had asked about coverage at the end of the day a few months ago. She’s not aware of any supervision problems. I asked the director and two staff what the cell phone policy was for the center. They all stated that staff are not allowed to use their cell phones during the day. The staff have the Class Dojo app on their phones that captures children’s activities throughout day. The app allows parents to send messages and staff will also send photos of children engaged in different activities. The director and staff stated that this doesn’t interfere with the care the children receive during the day. Proper supervision is being maintained. I observed the classroom occupied by the young three-year old children for about 15 minutes. The children were in center play activities. Both staff were moving about the classroom involved with the children then preparing to go outside. One staff prepared the children for their transition to outdoor play by explaining that soon they would need to clean up to go outside. After cleaning up the staff helped the children get their coats on then proceeded to the playground. I observed the children in outdoor play for about 30 minutes. All staff were moving about the playground interacting with the children. I did not observe groups of staff gathering in one area or anyone on cell phones. RESOLUTION Based on my interview findings and observations, I was unable to determine if proper supervision was not met. Therefore, this allegation is UNSUBSTANTIATED. ALLEGATION #2 *There are concerns related to a safe environment. FINDINGS I asked the director and staff if candles are burning during the day in the center. Both stated yes, in the office only to mask the smell of dirty diapers. The director stated that she wasn’t aware that candles are not allowed in the center. She also stated that the candles are not used in the classrooms. I did observe a candle (not burning) on top of a book case in the assistant director's office, but not in any classroom. The director removed the candle today. RESOLUTION Based on the interviews and my observations this allegation is SUBSTANTIATED. The following violations were observed, documented and technical assistance regarding maintaining compliance was offered. 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 last fire inspection was completed on 11/27/23. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. Candles are allowed to burn in the office. In space F the art supplies were stored on shelves in ziploc bags accessible to the children two years of age. 10A NCAC 09 .0601(a) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A letter of compliance must be sent to me by December 20, 2024. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number COMPLIANCE HISTORY SCORE Prior to the visit today the compliance history for the facility was 87%. The program was not in compliance with all applicable minimum licensing requirements during today's visit and violations were cited that could impact the center's overall Compliance History Score. According to NC General Statute 110-90 (4)(d) all facilities must maintain a compliance history of at least seventy-five percent (75%) for the past 18 months. TECHNICAL ASSISTANCE I explained to the director that candles, air fresheners, and oil diffusers with strong scents can be problematic for children and adults with allergies. Candles are not allowed in child care centers because of the open flame, and the children or adults could have a sensitivity to the chemicals. Please continue to check the Division of Child Development and Early Education website: ncchildcare.ncdhhs.gov frequently and click the “what’s new” tab to stay informed of all updated information available to you. If I can be of any assistance or if you have any questions, please feel free to contact me at (919) 819-9378. 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 .0304 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: KIA REID Operation Type: Center Case Number: 1124-216L Visit Date: 12/5/2024 Number Present: 79 Completed Date: 12/5/2024 Age: From 2 To 5 Total Minutes: 120 Time In: 09:30 AM Time Out: 11:30 AM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to investigate a report that was received November 20, 2024, alleging non-compliance of child care requirements. Lynn Lee, Director, was present and assisted me during the visit. The visit summary was completed off-site, emailed, and reviewed with Ms. Lee by telephone. Upon arrival, I was greeted by, the assistant director, Dana Hall. I completed a general walk through of six (6) classrooms with Ms. Lee. There were twelve (12) staff, and seventy-nine (79) children present on the visit today. The children were observed in routine care, circle time, center and outdoor activities. Limited monitoring of child care requirements was conducted during the visit. Supervision of children, staff/child ratios, general safety, use of adequate/approved space, and permit restrictions were monitored. The Notice of Compliance and emergency care plan were posted. During today’s visit, I discussed the allegations with the director and two staff. They were given an opportunity to provide information surrounding the allegations. ALLEGATION #1 There are concerns regarding supervision. FINDINGS I asked the director if she had any concerns from parents or staff concerning supervision. She stated the only thing she could think of was that a staff member had asked about coverage at the end of the day a few months ago. She’s not aware of any supervision problems. I asked the director and two staff what the cell phone policy was for the center. They all stated that staff are not allowed to use their cell phones during the day. The staff have the Class Dojo app on their phones that captures children’s activities throughout day. The app allows parents to send messages and staff will also send photos of children engaged in different activities. The director and staff stated that this doesn’t interfere with the care the children receive during the day. Proper supervision is being maintained. I observed the classroom occupied by the young three-year old children for about 15 minutes. The children were in center play activities. Both staff were moving about the classroom involved with the children then preparing to go outside. One staff prepared the children for their transition to outdoor play by explaining that soon they would need to clean up to go outside. After cleaning up the staff helped the children get their coats on then proceeded to the playground. I observed the children in outdoor play for about 30 minutes. All staff were moving about the playground interacting with the children. I did not observe groups of staff gathering in one area or anyone on cell phones. RESOLUTION Based on my interview findings and observations, I was unable to determine if proper supervision was not met. Therefore, this allegation is UNSUBSTANTIATED. ALLEGATION #2 *There are concerns related to a safe environment. FINDINGS I asked the director and staff if candles are burning during the day in the center. Both stated yes, in the office only to mask the smell of dirty diapers. The director stated that she wasn’t aware that candles are not allowed in the center. She also stated that the candles are not used in the classrooms. I did observe a candle (not burning) on top of a book case in the assistant director's office, but not in any classroom. The director removed the candle today. RESOLUTION Based on the interviews and my observations this allegation is SUBSTANTIATED. The following violations were observed, documented and technical assistance regarding maintaining compliance was offered. 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 last fire inspection was completed on 11/27/23. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. Candles are allowed to burn in the office. In space F the art supplies were stored on shelves in ziploc bags accessible to the children two years of age. 10A NCAC 09 .0601(a) In order to comply with the NC Laws and Rules any violations cited today must be corrected immediately. A letter of compliance must be sent to me by December 20, 2024. The letter must address each violation and explain how it has been corrected. Please send this to Kia.Reid@dhhs.nc.gov and include the following: -Facility name -Facility ID number -Each item number COMPLIANCE HISTORY SCORE Prior to the visit today the compliance history for the facility was 87%. The program was not in compliance with all applicable minimum licensing requirements during today's visit and violations were cited that could impact the center's overall Compliance History Score. According to NC General Statute 110-90 (4)(d) all facilities must maintain a compliance history of at least seventy-five percent (75%) for the past 18 months. TECHNICAL ASSISTANCE I explained to the director that candles, air fresheners, and oil diffusers with strong scents can be problematic for children and adults with allergies. Candles are not allowed in child care centers because of the open flame, and the children or adults could have a sensitivity to the chemicals. Please continue to check the Division of Child Development and Early Education website: ncchildcare.ncdhhs.gov frequently and click the “what’s new” tab to stay informed of all updated information available to you. If I can be of any assistance or if you have any questions, please feel free to contact me at (919) 819-9378. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0802 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: TONI FULLER Operation Type: Center Case Number: Visit Date: 5/1/2024 Number Present: 85 Completed Date: 5/1/2024 Age: From 2 To 5 Total Minutes: 240 Time In: 09:30 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced Upon arrival the assistant director greeted me. The director arrived from an appointment shortly after the visit began. The purpose of today’s visit was to monitor applicable child care requirements during an Annual Compliance visit. The last Annual Compliance visit was conducted on 5/9/23. This center operates with a Notice of Compliance, as a GS110-106 “church exempt” facility. The compliance history for this center for the previous eighteen-month timeframe was 91%. All indoor licensed space and the outdoor fenced-in spaces were monitored today. OBSERVATIONS: All the children were being visually supervised. I observed the children enjoying the outdoor environment, having story time, completing a teacher-directed activity on the number "4", and engaged in a variety of indoor activities. CHILDREN’S RECORDS: Eleven children’s records were randomly selected and reviewed today. STAFF FILES: I received the staff/training worksheet prior to today’s visit. The staff files were reviewed during today’s visit. INSPECTIONS: The last documented annual fire inspection was conducted on 11/27/23. The last documented sanitation inspection was conducted on 6/20/23. The last documented playground inspection was completed on 4/29/24. The last documented fire drill was conducted on 4/18/24. The last documented lockdown/shelter-in-place drill was conducted on 2/12/24. The following violations were cited today. Violation Number Comment Rule 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. There were three aerosol cans of disinfectant and sprays accessible to the children in the open room at the entrance to the cafeteria area. .2820(b) 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. There was no documentation that the EMC plan had been reviewed. 10A NCAC 09 .0802(a) 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. The First Aid training for one teacher expired in March 2024. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. The CPR training for one teacher expired in March 2024. .1102(d) 1825 All staff did not review the center's EPR Plan during orientation and/or on an annual basis with the trained staff. Documentation of the review was not maintained on file. There was no documentation that the EPR plan had been reviewed. .0607(f) 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, who had two seizures in 2023, needed a Medical Action Plan on file. .0801(b) All violations must be corrected immediately. Please send me a signed Corrective Action letter by 5/15/24, stating how each violation cited today has been corrected. TECHNICAL ASSISTANCE WAS PROVIDED ON THE FOLLOWING TOPICS: EPR and EMC REVIEW DOCUMENTATION: The director stated that both plans were reviewed annually during the August staff meeting. As discussed, and documented in the 5/9/23 visit summary, the center needed to maintain verification that the information was reviewed during the yearly staff meeting. AGENCY UPDATES: Mount Sylvan had documentation showing the completion of water testing on 10/24/23. Regarding the new requirement for Clean Classrooms for Carolina Kids, the director stated that she watched the video and completed the first step for lead and asbestos testing yesterday. CONTACT INFORMATION: Please contact me if I can be of any assistance to you. I can be reached at toni.fuller@dhhs.nc.gov or (919) 819-9366. 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.

GS110-106 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: TONI FULLER Operation Type: Center Case Number: Visit Date: 5/1/2024 Number Present: 85 Completed Date: 5/1/2024 Age: From 2 To 5 Total Minutes: 240 Time In: 09:30 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced Upon arrival the assistant director greeted me. The director arrived from an appointment shortly after the visit began. The purpose of today’s visit was to monitor applicable child care requirements during an Annual Compliance visit. The last Annual Compliance visit was conducted on 5/9/23. This center operates with a Notice of Compliance, as a GS110-106 “church exempt” facility. The compliance history for this center for the previous eighteen-month timeframe was 91%. All indoor licensed space and the outdoor fenced-in spaces were monitored today. OBSERVATIONS: All the children were being visually supervised. I observed the children enjoying the outdoor environment, having story time, completing a teacher-directed activity on the number "4", and engaged in a variety of indoor activities. CHILDREN’S RECORDS: Eleven children’s records were randomly selected and reviewed today. STAFF FILES: I received the staff/training worksheet prior to today’s visit. The staff files were reviewed during today’s visit. INSPECTIONS: The last documented annual fire inspection was conducted on 11/27/23. The last documented sanitation inspection was conducted on 6/20/23. The last documented playground inspection was completed on 4/29/24. The last documented fire drill was conducted on 4/18/24. The last documented lockdown/shelter-in-place drill was conducted on 2/12/24. The following violations were cited today. Violation Number Comment Rule 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. There were three aerosol cans of disinfectant and sprays accessible to the children in the open room at the entrance to the cafeteria area. .2820(b) 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. There was no documentation that the EMC plan had been reviewed. 10A NCAC 09 .0802(a) 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. The First Aid training for one teacher expired in March 2024. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. The CPR training for one teacher expired in March 2024. .1102(d) 1825 All staff did not review the center's EPR Plan during orientation and/or on an annual basis with the trained staff. Documentation of the review was not maintained on file. There was no documentation that the EPR plan had been reviewed. .0607(f) 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, who had two seizures in 2023, needed a Medical Action Plan on file. .0801(b) All violations must be corrected immediately. Please send me a signed Corrective Action letter by 5/15/24, stating how each violation cited today has been corrected. TECHNICAL ASSISTANCE WAS PROVIDED ON THE FOLLOWING TOPICS: EPR and EMC REVIEW DOCUMENTATION: The director stated that both plans were reviewed annually during the August staff meeting. As discussed, and documented in the 5/9/23 visit summary, the center needed to maintain verification that the information was reviewed during the yearly staff meeting. AGENCY UPDATES: Mount Sylvan had documentation showing the completion of water testing on 10/24/23. Regarding the new requirement for Clean Classrooms for Carolina Kids, the director stated that she watched the video and completed the first step for lead and asbestos testing yesterday. CONTACT INFORMATION: Please contact me if I can be of any assistance to you. I can be reached at toni.fuller@dhhs.nc.gov or (919) 819-9366. 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 .0601 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: TONI FULLER Operation Type: Center Case Number: Visit Date: 11/20/2023 Number Present: 71 Completed Date: 11/20/2023 Age: From 2 To 5 Total Minutes: 120 Time In: 11:30 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced Upon arrival the director greeted me. The purpose of today’s visit was to monitor child care requirements during a Routine Unannounced visit. The last Annual Compliance visit was conducted on 5/9/23. This facility operates with a Notice of Compliance, as a GS110-106, church-exempt program. The compliance history for this center for the previous eighteen-month timeframe is 92%. All indoor and outdoor licensed space was monitored today. Upon arrival the children in five of the six classrooms were outside playing. I observed the children returning from outdoor play and eating lunch in the cafeteria. STAFF FILES: From reviewing the staff/training worksheets for the 5/9/23 visit, I determined that the staff had current Criminal Record Check clearance and CPR/First Aid training. TRANSPORTATION: This center does not offer transportation services. INSPECTIONS: The last documented annual fire inspection was conducted on 11/4/22. The last documented sanitation inspection was conducted on 6/20/23. The last documented fire drill was conducted on 10/13/23. The last documented lockdown/shelter-in-place drill was conducted on 10/24/23. The last documented outdoor inspection was completed on 10/12/23. The following violations were cited today: 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 last documented approved fire inspection was dated 11/4/22. Durham Fire Inspections had not been contacted to request an updated inspection. 10A NCAC 09 .0304(a) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. There was no measurable surfacing under the swings on the smaller playground. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. The playground gate separating the two playground spaces was broken. 10A NCAC 09 .0601(a) All violations must be corrected immediately. Please send me a signed Corrective Action letter by 12/4/23, stating how the violation cited today has been corrected. ANNUAL FIRE INSPECTION: The director stated that she knew that the annual Fire Inspection was due, but she had not contacted Durham Fire Inspections to request an inspection, based on working out solutions from the 2022 fire inspection. The content of the 2022 fire inspection was reviewed during the visit. The director left a voice message for Greg Boykin with Durham Fire Inspections during today’s visit. I talked with the licensing supervisor during the visit about this matter. The director may telephone Durham Building Inspections to discuss institutional building zones, as they relate to NC fire codes. NUTRITION REQUIREMENTS: According to the allergy list, posted in the eating area, four children were listed as “no milk – preference”, and two children were listed as “no daily products – preference”. The director stated that all the children were provided/offered milk at mealtime, and the children were given water when they did not drink the milk. The director was aware that milk was a requirement, in accordance with the NC Child Care Nutrition requirements. CONTACT INFORMATION: Please contact me if I can be of any assistance to you. I can be reached at toni.fuller@dhhs.nc.gov or (919) 819-9366. 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 .0304 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: TONI FULLER Operation Type: Center Case Number: Visit Date: 11/20/2023 Number Present: 71 Completed Date: 11/20/2023 Age: From 2 To 5 Total Minutes: 120 Time In: 11:30 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced Upon arrival the director greeted me. The purpose of today’s visit was to monitor child care requirements during a Routine Unannounced visit. The last Annual Compliance visit was conducted on 5/9/23. This facility operates with a Notice of Compliance, as a GS110-106, church-exempt program. The compliance history for this center for the previous eighteen-month timeframe is 92%. All indoor and outdoor licensed space was monitored today. Upon arrival the children in five of the six classrooms were outside playing. I observed the children returning from outdoor play and eating lunch in the cafeteria. STAFF FILES: From reviewing the staff/training worksheets for the 5/9/23 visit, I determined that the staff had current Criminal Record Check clearance and CPR/First Aid training. TRANSPORTATION: This center does not offer transportation services. INSPECTIONS: The last documented annual fire inspection was conducted on 11/4/22. The last documented sanitation inspection was conducted on 6/20/23. The last documented fire drill was conducted on 10/13/23. The last documented lockdown/shelter-in-place drill was conducted on 10/24/23. The last documented outdoor inspection was completed on 10/12/23. The following violations were cited today: 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 last documented approved fire inspection was dated 11/4/22. Durham Fire Inspections had not been contacted to request an updated inspection. 10A NCAC 09 .0304(a) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. There was no measurable surfacing under the swings on the smaller playground. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. The playground gate separating the two playground spaces was broken. 10A NCAC 09 .0601(a) All violations must be corrected immediately. Please send me a signed Corrective Action letter by 12/4/23, stating how the violation cited today has been corrected. ANNUAL FIRE INSPECTION: The director stated that she knew that the annual Fire Inspection was due, but she had not contacted Durham Fire Inspections to request an inspection, based on working out solutions from the 2022 fire inspection. The content of the 2022 fire inspection was reviewed during the visit. The director left a voice message for Greg Boykin with Durham Fire Inspections during today’s visit. I talked with the licensing supervisor during the visit about this matter. The director may telephone Durham Building Inspections to discuss institutional building zones, as they relate to NC fire codes. NUTRITION REQUIREMENTS: According to the allergy list, posted in the eating area, four children were listed as “no milk – preference”, and two children were listed as “no daily products – preference”. The director stated that all the children were provided/offered milk at mealtime, and the children were given water when they did not drink the milk. The director was aware that milk was a requirement, in accordance with the NC Child Care Nutrition requirements. CONTACT INFORMATION: Please contact me if I can be of any assistance to you. I can be reached at toni.fuller@dhhs.nc.gov or (919) 819-9366. 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

GS110-106 · Violation

Name of Operation: MOUNT SYLVAN UNITED METHODIST Facility ID: 32000334 Consultant: TONI FULLER Operation Type: Center Case Number: Visit Date: 11/20/2023 Number Present: 71 Completed Date: 11/20/2023 Age: From 2 To 5 Total Minutes: 120 Time In: 11:30 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced Upon arrival the director greeted me. The purpose of today’s visit was to monitor child care requirements during a Routine Unannounced visit. The last Annual Compliance visit was conducted on 5/9/23. This facility operates with a Notice of Compliance, as a GS110-106, church-exempt program. The compliance history for this center for the previous eighteen-month timeframe is 92%. All indoor and outdoor licensed space was monitored today. Upon arrival the children in five of the six classrooms were outside playing. I observed the children returning from outdoor play and eating lunch in the cafeteria. STAFF FILES: From reviewing the staff/training worksheets for the 5/9/23 visit, I determined that the staff had current Criminal Record Check clearance and CPR/First Aid training. TRANSPORTATION: This center does not offer transportation services. INSPECTIONS: The last documented annual fire inspection was conducted on 11/4/22. The last documented sanitation inspection was conducted on 6/20/23. The last documented fire drill was conducted on 10/13/23. The last documented lockdown/shelter-in-place drill was conducted on 10/24/23. The last documented outdoor inspection was completed on 10/12/23. The following violations were cited today: 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 last documented approved fire inspection was dated 11/4/22. Durham Fire Inspections had not been contacted to request an updated inspection. 10A NCAC 09 .0304(a) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. There was no measurable surfacing under the swings on the smaller playground. .0605(j) 807 A safe indoor and outdoor environment was not provided for the children. The playground gate separating the two playground spaces was broken. 10A NCAC 09 .0601(a) All violations must be corrected immediately. Please send me a signed Corrective Action letter by 12/4/23, stating how the violation cited today has been corrected. ANNUAL FIRE INSPECTION: The director stated that she knew that the annual Fire Inspection was due, but she had not contacted Durham Fire Inspections to request an inspection, based on working out solutions from the 2022 fire inspection. The content of the 2022 fire inspection was reviewed during the visit. The director left a voice message for Greg Boykin with Durham Fire Inspections during today’s visit. I talked with the licensing supervisor during the visit about this matter. The director may telephone Durham Building Inspections to discuss institutional building zones, as they relate to NC fire codes. NUTRITION REQUIREMENTS: According to the allergy list, posted in the eating area, four children were listed as “no milk – preference”, and two children were listed as “no daily products – preference”. The director stated that all the children were provided/offered milk at mealtime, and the children were given water when they did not drink the milk. The director was aware that milk was a requirement, in accordance with the NC Child Care Nutrition requirements. CONTACT INFORMATION: Please contact me if I can be of any assistance to you. I can be reached at toni.fuller@dhhs.nc.gov or (919) 819-9366. 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