10A NCAC 09 .0605 · Violation

Name of Operation: Elizabethtown Christian Academy Facility ID: 09000162 Consultant: MIRIAM BYRD Operation Type: Center Case Number: Visit Date: 11/13/2025 Number Present: 16 Completed Date: 11/13/2025 Age: From 4 To 5 Total Minutes: 150 Time In: 10:30 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 unannounced visit was to monitor applicable childcare requirements during a Routine Unannounced visit. Today’s visit was conducted with Amy Reeves, Christian Academy Headmaster. The program operates with a Notice of Compliance issued August 22, 2025. The first day of attendance for the students was August 25, 2025. I completed a general walk-through of the indoor and outdoor areas used by the children. I monitored the required postings, attendance logs, program records, equipment and furnishings, staff/child ratios & supervision, and outdoor area & equipment. I observed sixteen (16) preschool aged children present with two staff, completing their snack in space #1. I observed children washing their hands and transitioning to a circle time activity. A sanitation inspection was completed on September 22, 2025 with 0 demerits and a Superior rating. The Emergency Drill Log form was monitored during today's visit. The last fire drill was conducted on October 29, 2025 at 3:53 pm with 16 children, and 3 adults participating in the drill. The Alarm system was used to signal the drill. A shelter-in-place/lockdown drill must be completed by 11-25-2025. Two new staff files were reviewed during today's visit. There were six violations of child care requirements observed and documented during today's visit. Each were thoroughly reviewed with Mrs. Reeves. The Visit Summary report was printed at the conclusion of today's visit and a copy was left with Mrs. Reeves. Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Documentation of the Emergency Medical Care Plan was not completed for two staff. 10A NCAC 09 .0802(a) 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 did not have a completed medical report on file prior to employment. 10A NCAC 09 .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff file did not have a completed Emergency Information form on file on or before the first day of work. .0701(a) 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. Two staff files did not have documentation of completion of the review of the center's EPR Plan. .0607(f) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Two staff files had the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy on file; however, there was no signature or date of acknowledgement. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Two staff files reviewed did not maintain the medical report, proof of TB test/screening and health questionnaire separately. .0701(d) The violations documented must be corrected immediately. Due to the Thanksgiving Holiday, I must receive a written response on or before December 1, 2025. Make sure the compliance letter describes accurately and in detail, how and when the violations were corrected. You may email or mail the information to: Miriam.Byrd@dhhs.nc.gov. If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. Child care licensing requirements were established to ensure a safe and healthy child care environment. Therefore, it is important for you to be knowledgeable of all the licensing requirements that apply to your type of program. It is your responsibility to maintain compliance with all the applicable laws and rules at all times. The best way for you to make sure that you are meeting all requirements is to periodically review the child care law and rules. Make sure you visit the Division of Child Development's website (www.ncchildcare.nc.gov) on a regular basis to find out what's new in childcare. You can also find any needed Child Care forms by going on the web site and clicking on the "Provider" tab and then clicking on the "Provider Documents" tab. You are required to maintain compliance with all applicable child care rules and regulations at all times. NC GS 110- 90(4)(d) requires all child care facilities to maintain a compliance history score of at least 75% for the past 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. Your current compliance history score is 93% from 5/12/2024 to November 11, 2025. ABCMS Provider Portal: I verified during today's visit that your facility and five staff are registered on the ABCMS Provider Portal. Make sure to update this roster whenever a new staff is hired or when changes occur with the existing staff. Technical assistance with the following was provided during today's visit: 1. Staff records- Make sure to review the required documents upon receipt to ensure all are complete and accurate. It was discussed that medical information (medical statements, health questionnaires and TB test results) must be kept in a separate, confidential file apart from the general personnel file. Make sure to use the staff checklist form provided by DCDEE to ensure compliance with record-keeping information. 2. A play structure is being installed on the outdoor playground space. This area is roped off with construction netting to keep children away from the area. Once the climber is complete, with fall zone and surfacing, I will need to approve the structure before children can utilize it. The following was discussed with Mrs. Reeves- *Any stationary outdoor equipment more than 18 inches high must be installed over protective surfacing *The surfacing, "fall zone" area, around and under equipment must extend beyond the external limits of the equipment. For children 2 years and older, this is minimum of 6 feet, so that a fall won't land on the hard unsafe area *The depth of loose surfacing material depends on the "critical height" (the maximum height a child may sit/stands on the piece). If the equipment critical height is less than 5 feet, at least 6 inches of loose surface material is required. If the equipment critical height is 7-10 feet, at least 9 inches of loose surface material is required. *Protective surfacing shall be either: *Loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or *Other materials that have been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). Make sure to review the Outdoor Learning Environment in Child Care Centers found in the Child Care Rules 10A NCAC 09 .0605. I noticed two benches are on the outdoor learning environment. I reminded Mrs. Reeves that children must be actively supervised at all times while in the outdoor learning environment. Teachers should position themselves so all areas of the playground are visible and ensure that children are always within sight and sound. Make sure staff remain attentive, moving throughout the area as needed, and interact with children to ensure safety and appropriate play. Contact me at (910) 709-5985 or via email if you have any questions or concerns. You may also contact Janet Edwards, Licensing Supervisor, at (910) 709-4160, janet.edwards@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0701 · Violation

Name of Operation: Elizabethtown Christian Academy Facility ID: 09000162 Consultant: MIRIAM BYRD Operation Type: Center Case Number: Visit Date: 11/13/2025 Number Present: 16 Completed Date: 11/13/2025 Age: From 4 To 5 Total Minutes: 150 Time In: 10:30 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 unannounced visit was to monitor applicable childcare requirements during a Routine Unannounced visit. Today’s visit was conducted with Amy Reeves, Christian Academy Headmaster. The program operates with a Notice of Compliance issued August 22, 2025. The first day of attendance for the students was August 25, 2025. I completed a general walk-through of the indoor and outdoor areas used by the children. I monitored the required postings, attendance logs, program records, equipment and furnishings, staff/child ratios & supervision, and outdoor area & equipment. I observed sixteen (16) preschool aged children present with two staff, completing their snack in space #1. I observed children washing their hands and transitioning to a circle time activity. A sanitation inspection was completed on September 22, 2025 with 0 demerits and a Superior rating. The Emergency Drill Log form was monitored during today's visit. The last fire drill was conducted on October 29, 2025 at 3:53 pm with 16 children, and 3 adults participating in the drill. The Alarm system was used to signal the drill. A shelter-in-place/lockdown drill must be completed by 11-25-2025. Two new staff files were reviewed during today's visit. There were six violations of child care requirements observed and documented during today's visit. Each were thoroughly reviewed with Mrs. Reeves. The Visit Summary report was printed at the conclusion of today's visit and a copy was left with Mrs. Reeves. Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Documentation of the Emergency Medical Care Plan was not completed for two staff. 10A NCAC 09 .0802(a) 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 did not have a completed medical report on file prior to employment. 10A NCAC 09 .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff file did not have a completed Emergency Information form on file on or before the first day of work. .0701(a) 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. Two staff files did not have documentation of completion of the review of the center's EPR Plan. .0607(f) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Two staff files had the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy on file; however, there was no signature or date of acknowledgement. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Two staff files reviewed did not maintain the medical report, proof of TB test/screening and health questionnaire separately. .0701(d) The violations documented must be corrected immediately. Due to the Thanksgiving Holiday, I must receive a written response on or before December 1, 2025. Make sure the compliance letter describes accurately and in detail, how and when the violations were corrected. You may email or mail the information to: Miriam.Byrd@dhhs.nc.gov. If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. Child care licensing requirements were established to ensure a safe and healthy child care environment. Therefore, it is important for you to be knowledgeable of all the licensing requirements that apply to your type of program. It is your responsibility to maintain compliance with all the applicable laws and rules at all times. The best way for you to make sure that you are meeting all requirements is to periodically review the child care law and rules. Make sure you visit the Division of Child Development's website (www.ncchildcare.nc.gov) on a regular basis to find out what's new in childcare. You can also find any needed Child Care forms by going on the web site and clicking on the "Provider" tab and then clicking on the "Provider Documents" tab. You are required to maintain compliance with all applicable child care rules and regulations at all times. NC GS 110- 90(4)(d) requires all child care facilities to maintain a compliance history score of at least 75% for the past 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. Your current compliance history score is 93% from 5/12/2024 to November 11, 2025. ABCMS Provider Portal: I verified during today's visit that your facility and five staff are registered on the ABCMS Provider Portal. Make sure to update this roster whenever a new staff is hired or when changes occur with the existing staff. Technical assistance with the following was provided during today's visit: 1. Staff records- Make sure to review the required documents upon receipt to ensure all are complete and accurate. It was discussed that medical information (medical statements, health questionnaires and TB test results) must be kept in a separate, confidential file apart from the general personnel file. Make sure to use the staff checklist form provided by DCDEE to ensure compliance with record-keeping information. 2. A play structure is being installed on the outdoor playground space. This area is roped off with construction netting to keep children away from the area. Once the climber is complete, with fall zone and surfacing, I will need to approve the structure before children can utilize it. The following was discussed with Mrs. Reeves- *Any stationary outdoor equipment more than 18 inches high must be installed over protective surfacing *The surfacing, "fall zone" area, around and under equipment must extend beyond the external limits of the equipment. For children 2 years and older, this is minimum of 6 feet, so that a fall won't land on the hard unsafe area *The depth of loose surfacing material depends on the "critical height" (the maximum height a child may sit/stands on the piece). If the equipment critical height is less than 5 feet, at least 6 inches of loose surface material is required. If the equipment critical height is 7-10 feet, at least 9 inches of loose surface material is required. *Protective surfacing shall be either: *Loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or *Other materials that have been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). Make sure to review the Outdoor Learning Environment in Child Care Centers found in the Child Care Rules 10A NCAC 09 .0605. I noticed two benches are on the outdoor learning environment. I reminded Mrs. Reeves that children must be actively supervised at all times while in the outdoor learning environment. Teachers should position themselves so all areas of the playground are visible and ensure that children are always within sight and sound. Make sure staff remain attentive, moving throughout the area as needed, and interact with children to ensure safety and appropriate play. Contact me at (910) 709-5985 or via email if you have any questions or concerns. You may also contact Janet Edwards, Licensing Supervisor, at (910) 709-4160, janet.edwards@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0802 · Violation

Name of Operation: Elizabethtown Christian Academy Facility ID: 09000162 Consultant: MIRIAM BYRD Operation Type: Center Case Number: Visit Date: 11/13/2025 Number Present: 16 Completed Date: 11/13/2025 Age: From 4 To 5 Total Minutes: 150 Time In: 10:30 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 unannounced visit was to monitor applicable childcare requirements during a Routine Unannounced visit. Today’s visit was conducted with Amy Reeves, Christian Academy Headmaster. The program operates with a Notice of Compliance issued August 22, 2025. The first day of attendance for the students was August 25, 2025. I completed a general walk-through of the indoor and outdoor areas used by the children. I monitored the required postings, attendance logs, program records, equipment and furnishings, staff/child ratios & supervision, and outdoor area & equipment. I observed sixteen (16) preschool aged children present with two staff, completing their snack in space #1. I observed children washing their hands and transitioning to a circle time activity. A sanitation inspection was completed on September 22, 2025 with 0 demerits and a Superior rating. The Emergency Drill Log form was monitored during today's visit. The last fire drill was conducted on October 29, 2025 at 3:53 pm with 16 children, and 3 adults participating in the drill. The Alarm system was used to signal the drill. A shelter-in-place/lockdown drill must be completed by 11-25-2025. Two new staff files were reviewed during today's visit. There were six violations of child care requirements observed and documented during today's visit. Each were thoroughly reviewed with Mrs. Reeves. The Visit Summary report was printed at the conclusion of today's visit and a copy was left with Mrs. Reeves. Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Documentation of the Emergency Medical Care Plan was not completed for two staff. 10A NCAC 09 .0802(a) 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 did not have a completed medical report on file prior to employment. 10A NCAC 09 .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff file did not have a completed Emergency Information form on file on or before the first day of work. .0701(a) 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. Two staff files did not have documentation of completion of the review of the center's EPR Plan. .0607(f) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Two staff files had the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy on file; however, there was no signature or date of acknowledgement. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Two staff files reviewed did not maintain the medical report, proof of TB test/screening and health questionnaire separately. .0701(d) The violations documented must be corrected immediately. Due to the Thanksgiving Holiday, I must receive a written response on or before December 1, 2025. Make sure the compliance letter describes accurately and in detail, how and when the violations were corrected. You may email or mail the information to: Miriam.Byrd@dhhs.nc.gov. If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. Child care licensing requirements were established to ensure a safe and healthy child care environment. Therefore, it is important for you to be knowledgeable of all the licensing requirements that apply to your type of program. It is your responsibility to maintain compliance with all the applicable laws and rules at all times. The best way for you to make sure that you are meeting all requirements is to periodically review the child care law and rules. Make sure you visit the Division of Child Development's website (www.ncchildcare.nc.gov) on a regular basis to find out what's new in childcare. You can also find any needed Child Care forms by going on the web site and clicking on the "Provider" tab and then clicking on the "Provider Documents" tab. You are required to maintain compliance with all applicable child care rules and regulations at all times. NC GS 110- 90(4)(d) requires all child care facilities to maintain a compliance history score of at least 75% for the past 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. Your current compliance history score is 93% from 5/12/2024 to November 11, 2025. ABCMS Provider Portal: I verified during today's visit that your facility and five staff are registered on the ABCMS Provider Portal. Make sure to update this roster whenever a new staff is hired or when changes occur with the existing staff. Technical assistance with the following was provided during today's visit: 1. Staff records- Make sure to review the required documents upon receipt to ensure all are complete and accurate. It was discussed that medical information (medical statements, health questionnaires and TB test results) must be kept in a separate, confidential file apart from the general personnel file. Make sure to use the staff checklist form provided by DCDEE to ensure compliance with record-keeping information. 2. A play structure is being installed on the outdoor playground space. This area is roped off with construction netting to keep children away from the area. Once the climber is complete, with fall zone and surfacing, I will need to approve the structure before children can utilize it. The following was discussed with Mrs. Reeves- *Any stationary outdoor equipment more than 18 inches high must be installed over protective surfacing *The surfacing, "fall zone" area, around and under equipment must extend beyond the external limits of the equipment. For children 2 years and older, this is minimum of 6 feet, so that a fall won't land on the hard unsafe area *The depth of loose surfacing material depends on the "critical height" (the maximum height a child may sit/stands on the piece). If the equipment critical height is less than 5 feet, at least 6 inches of loose surface material is required. If the equipment critical height is 7-10 feet, at least 9 inches of loose surface material is required. *Protective surfacing shall be either: *Loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or *Other materials that have been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). Make sure to review the Outdoor Learning Environment in Child Care Centers found in the Child Care Rules 10A NCAC 09 .0605. I noticed two benches are on the outdoor learning environment. I reminded Mrs. Reeves that children must be actively supervised at all times while in the outdoor learning environment. Teachers should position themselves so all areas of the playground are visible and ensure that children are always within sight and sound. Make sure staff remain attentive, moving throughout the area as needed, and interact with children to ensure safety and appropriate play. Contact me at (910) 709-5985 or via email if you have any questions or concerns. You may also contact Janet Edwards, Licensing Supervisor, at (910) 709-4160, janet.edwards@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

NC GS 110- 90 · Violation

Name of Operation: Elizabethtown Christian Academy Facility ID: 09000162 Consultant: MIRIAM BYRD Operation Type: Center Case Number: Visit Date: 11/13/2025 Number Present: 16 Completed Date: 11/13/2025 Age: From 4 To 5 Total Minutes: 150 Time In: 10:30 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 unannounced visit was to monitor applicable childcare requirements during a Routine Unannounced visit. Today’s visit was conducted with Amy Reeves, Christian Academy Headmaster. The program operates with a Notice of Compliance issued August 22, 2025. The first day of attendance for the students was August 25, 2025. I completed a general walk-through of the indoor and outdoor areas used by the children. I monitored the required postings, attendance logs, program records, equipment and furnishings, staff/child ratios & supervision, and outdoor area & equipment. I observed sixteen (16) preschool aged children present with two staff, completing their snack in space #1. I observed children washing their hands and transitioning to a circle time activity. A sanitation inspection was completed on September 22, 2025 with 0 demerits and a Superior rating. The Emergency Drill Log form was monitored during today's visit. The last fire drill was conducted on October 29, 2025 at 3:53 pm with 16 children, and 3 adults participating in the drill. The Alarm system was used to signal the drill. A shelter-in-place/lockdown drill must be completed by 11-25-2025. Two new staff files were reviewed during today's visit. There were six violations of child care requirements observed and documented during today's visit. Each were thoroughly reviewed with Mrs. Reeves. The Visit Summary report was printed at the conclusion of today's visit and a copy was left with Mrs. Reeves. Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Documentation of the Emergency Medical Care Plan was not completed for two staff. 10A NCAC 09 .0802(a) 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 did not have a completed medical report on file prior to employment. 10A NCAC 09 .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff file did not have a completed Emergency Information form on file on or before the first day of work. .0701(a) 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. Two staff files did not have documentation of completion of the review of the center's EPR Plan. .0607(f) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Two staff files had the Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy on file; however, there was no signature or date of acknowledgement. .0608(d)(1-4) 1890 Each staff member did not have the required medical report, proof of tuberculosis test or screening and/or completed health questionnaire in a medical file, maintained separately from the staff member's individual personnel file. Two staff files reviewed did not maintain the medical report, proof of TB test/screening and health questionnaire separately. .0701(d) The violations documented must be corrected immediately. Due to the Thanksgiving Holiday, I must receive a written response on or before December 1, 2025. Make sure the compliance letter describes accurately and in detail, how and when the violations were corrected. You may email or mail the information to: Miriam.Byrd@dhhs.nc.gov. If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. Child care licensing requirements were established to ensure a safe and healthy child care environment. Therefore, it is important for you to be knowledgeable of all the licensing requirements that apply to your type of program. It is your responsibility to maintain compliance with all the applicable laws and rules at all times. The best way for you to make sure that you are meeting all requirements is to periodically review the child care law and rules. Make sure you visit the Division of Child Development's website (www.ncchildcare.nc.gov) on a regular basis to find out what's new in childcare. You can also find any needed Child Care forms by going on the web site and clicking on the "Provider" tab and then clicking on the "Provider Documents" tab. You are required to maintain compliance with all applicable child care rules and regulations at all times. NC GS 110- 90(4)(d) requires all child care facilities to maintain a compliance history score of at least 75% for the past 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. Your current compliance history score is 93% from 5/12/2024 to November 11, 2025. ABCMS Provider Portal: I verified during today's visit that your facility and five staff are registered on the ABCMS Provider Portal. Make sure to update this roster whenever a new staff is hired or when changes occur with the existing staff. Technical assistance with the following was provided during today's visit: 1. Staff records- Make sure to review the required documents upon receipt to ensure all are complete and accurate. It was discussed that medical information (medical statements, health questionnaires and TB test results) must be kept in a separate, confidential file apart from the general personnel file. Make sure to use the staff checklist form provided by DCDEE to ensure compliance with record-keeping information. 2. A play structure is being installed on the outdoor playground space. This area is roped off with construction netting to keep children away from the area. Once the climber is complete, with fall zone and surfacing, I will need to approve the structure before children can utilize it. The following was discussed with Mrs. Reeves- *Any stationary outdoor equipment more than 18 inches high must be installed over protective surfacing *The surfacing, "fall zone" area, around and under equipment must extend beyond the external limits of the equipment. For children 2 years and older, this is minimum of 6 feet, so that a fall won't land on the hard unsafe area *The depth of loose surfacing material depends on the "critical height" (the maximum height a child may sit/stands on the piece). If the equipment critical height is less than 5 feet, at least 6 inches of loose surface material is required. If the equipment critical height is 7-10 feet, at least 9 inches of loose surface material is required. *Protective surfacing shall be either: *Loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or *Other materials that have been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). Make sure to review the Outdoor Learning Environment in Child Care Centers found in the Child Care Rules 10A NCAC 09 .0605. I noticed two benches are on the outdoor learning environment. I reminded Mrs. Reeves that children must be actively supervised at all times while in the outdoor learning environment. Teachers should position themselves so all areas of the playground are visible and ensure that children are always within sight and sound. Make sure staff remain attentive, moving throughout the area as needed, and interact with children to ensure safety and appropriate play. Contact me at (910) 709-5985 or via email if you have any questions or concerns. You may also contact Janet Edwards, Licensing Supervisor, at (910) 709-4160, janet.edwards@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