Immaculata Catholic Prek

10A NCAC 09 .0604 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-90 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

GS110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/11/2026 Number Present: 24 Completed Date: 5/11/2026 Age: From 3 To 5 Total Minutes: 250 Time In: 09:20 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Administrator, accompanied me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 5/10/2026. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. The last annual compliance visit was conducted on 5/22/2025. The last fire drill was practiced on 4/30/2026. The last lockdown drill was practiced on 3/25/2026. The last playground inspection was documented on 4/15/2026. The last fire inspection was approved on 2/16/2025. The last sanitation inspection was conducted on 1/16/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. Upon arrival I introduced my presence to Andrea Avery, Administrator. I observed the group with three-to-four-year-old children having free choice play and snack in the classroom. The four- to five-year-old children were participating in cleaning up from free play and transitioning to a large group yoga activity. Two (2) emergency medications were monitored for child care requirements. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today's visit Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file is dated 2/16/2025. 10A NCAC 09 .0304(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. Electrical outlets were not covered on the counter in Pre-K 4. 10A NCAC 09 .0604(c) 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. An aerosol can of Lysol was stored in an unlocked cabinet in Pre-K 4. .2820(b) 1321 Medical exam or health assessment record was not on file before or within 30 days after admission. A medical exam or health assessment was not on file for child, S.P. Refer to the children's records document. GS110-91(1) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. Only newly hired staff and the administrator are listed on the facility's ABCMS roster. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 10/13/2025, the next lockdown or shelter-in-place drill was practiced in February 2026. .0604(u);.0302(d)(8) 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. Two staff, per the staff and training worksheets, did not complete this required training within 90 days of employment. .1102(g) Technical assistance provided as follows 106- To achieve compliance, schedule a fire inspection immediately and plan to schedule another inspection in April of 2027. 1321- To achieve compliance, obtain a medical statement or health assessment for S.P. and place in their file. Plan to use a calendar to track records that are due within 30 days of enrollment. 1811- To achieve compliance, schedule a lock down or shelter-in-place drill every three months on an electronic calendar with reminders. 1897- To achieve compliance, track required trainings with a calendar for each employee. 1805- To achieve compliance, follow the instructions provided to you during today's visit to complete listing all staff on the ABCMS roster. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. 840; 812- Corrected during the visit. Plan to have staff do a daily inspection of the classrooms to prevent these violations. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Name and position of individual submitting compliance statement • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 5/25/2026. Email the compliance letter on signed letterhead or it must be sent from the email address registered with the DCDEE (this serves as your signature) to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 11/20/2025 Number Present: 21 Completed Date: 11/20/2025 Age: From 3 To 5 Total Minutes: 170 Time In: 10:00 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, Andrea Avery, Director, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for your records. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. Upon arrival, I made my presence known to Margarete Beale, Principal, Andrea Avery Director, approximately fifteen (15) minutes after my arrival. Ms. Beale and Ms. Avery were available to assist during the visit. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. The three to five-year-old children were having free play on the playground. They were observed running, rolling and tossing hula hoops, looking at books, playing with scarves and dramatic play items, having ball play and socializing. A fire drill was practiced during today’s visit. All interactions were appropriate and positive. Supervision was adequate. There are two (2) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background qualifying letters, CPR, FA, and other required training courses. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today’s visit. Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. .0604(t); .0302(d)(5) 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. 10A NCAC 09 .0701(a) Technical assistance provided 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. You stated that the statements had once been filed and had been removed. You stated you will have the staff members return the statements or get copies for the files. 805-Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. You stated that you are sure a fire drill was practiced and was failed to be documented. Plan to make a reminder to immediately document fire and other emergency drills as they are practiced. Achieving compliance 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 comptafliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 12/4/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766. Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0701 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 11/20/2025 Number Present: 21 Completed Date: 11/20/2025 Age: From 3 To 5 Total Minutes: 170 Time In: 10:00 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, Andrea Avery, Director, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for your records. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. Upon arrival, I made my presence known to Margarete Beale, Principal, Andrea Avery Director, approximately fifteen (15) minutes after my arrival. Ms. Beale and Ms. Avery were available to assist during the visit. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. The three to five-year-old children were having free play on the playground. They were observed running, rolling and tossing hula hoops, looking at books, playing with scarves and dramatic play items, having ball play and socializing. A fire drill was practiced during today’s visit. All interactions were appropriate and positive. Supervision was adequate. There are two (2) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background qualifying letters, CPR, FA, and other required training courses. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today’s visit. Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. .0604(t); .0302(d)(5) 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. 10A NCAC 09 .0701(a) Technical assistance provided 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. You stated that the statements had once been filed and had been removed. You stated you will have the staff members return the statements or get copies for the files. 805-Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. You stated that you are sure a fire drill was practiced and was failed to be documented. Plan to make a reminder to immediately document fire and other emergency drills as they are practiced. Achieving compliance 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 comptafliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 12/4/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766. Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 11/20/2025 Number Present: 21 Completed Date: 11/20/2025 Age: From 3 To 5 Total Minutes: 170 Time In: 10:00 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, Andrea Avery, Director, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for your records. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. Upon arrival, I made my presence known to Margarete Beale, Principal, Andrea Avery Director, approximately fifteen (15) minutes after my arrival. Ms. Beale and Ms. Avery were available to assist during the visit. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. The three to five-year-old children were having free play on the playground. They were observed running, rolling and tossing hula hoops, looking at books, playing with scarves and dramatic play items, having ball play and socializing. A fire drill was practiced during today’s visit. All interactions were appropriate and positive. Supervision was adequate. There are two (2) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background qualifying letters, CPR, FA, and other required training courses. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today’s visit. Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. .0604(t); .0302(d)(5) 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. 10A NCAC 09 .0701(a) Technical assistance provided 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. You stated that the statements had once been filed and had been removed. You stated you will have the staff members return the statements or get copies for the files. 805-Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. You stated that you are sure a fire drill was practiced and was failed to be documented. Plan to make a reminder to immediately document fire and other emergency drills as they are practiced. Achieving compliance 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 comptafliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 12/4/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766. Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 11/20/2025 Number Present: 21 Completed Date: 11/20/2025 Age: From 3 To 5 Total Minutes: 170 Time In: 10:00 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, Andrea Avery, Director, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for your records. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. Upon arrival, I made my presence known to Margarete Beale, Principal, Andrea Avery Director, approximately fifteen (15) minutes after my arrival. Ms. Beale and Ms. Avery were available to assist during the visit. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. The three to five-year-old children were having free play on the playground. They were observed running, rolling and tossing hula hoops, looking at books, playing with scarves and dramatic play items, having ball play and socializing. A fire drill was practiced during today’s visit. All interactions were appropriate and positive. Supervision was adequate. There are two (2) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background qualifying letters, CPR, FA, and other required training courses. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today’s visit. Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. .0604(t); .0302(d)(5) 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. 10A NCAC 09 .0701(a) Technical assistance provided 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. You stated that the statements had once been filed and had been removed. You stated you will have the staff members return the statements or get copies for the files. 805-Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. You stated that you are sure a fire drill was practiced and was failed to be documented. Plan to make a reminder to immediately document fire and other emergency drills as they are practiced. Achieving compliance 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 comptafliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 12/4/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766. Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 11/20/2025 Number Present: 21 Completed Date: 11/20/2025 Age: From 3 To 5 Total Minutes: 170 Time In: 10:00 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, Andrea Avery, Director, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for your records. This program operates as a GS-110; Religious-sponsored child care center, issued 8/12/2025. Restrictions – Daytime care only; Children cared for on ground level only. Upon arrival, I made my presence known to Margarete Beale, Principal, Andrea Avery Director, approximately fifteen (15) minutes after my arrival. Ms. Beale and Ms. Avery were available to assist during the visit. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. The three to five-year-old children were having free play on the playground. They were observed running, rolling and tossing hula hoops, looking at books, playing with scarves and dramatic play items, having ball play and socializing. A fire drill was practiced during today’s visit. All interactions were appropriate and positive. Supervision was adequate. There are two (2) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background qualifying letters, CPR, FA, and other required training courses. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The program does not provide transportation. The following violations were documented during today’s visit. Violation Number Comment Rule 805 Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. .0604(t); .0302(d)(5) 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. 10A NCAC 09 .0701(a) Technical assistance provided 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. Staff M.M, hired 8/22/25 and N.G., hired 3/10/25 did not have medical reports on file. You stated that the statements had once been filed and had been removed. You stated you will have the staff members return the statements or get copies for the files. 805-Fire drills were not practiced monthly and/or the drill record was incomplete. A fire drill for October 2025 was not documented. You stated that you are sure a fire drill was practiced and was failed to be documented. Plan to make a reminder to immediately document fire and other emergency drills as they are practiced. Achieving compliance 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 comptafliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 12/4/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766. Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0508 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0514 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0803 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1103 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2830 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-106 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-90 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

GS 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 5/22/2025 Number Present: 28 Completed Date: 5/22/2025 Age: From 3 To 5 Total Minutes: 255 Time In: 09:30 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. An electronic signed copy of the visit summary was left on-site. Today, Andrea Avery, Director, was available to assist me. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was seventy (70) percentage as of 05/21/2025. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 8/19/24. The last fire drill was practiced on 4/30/25. The last lockdown drill was practiced on 4/2/25. The last playground inspection was documented on 4/28/25. The last fire inspection was approved on 2/16/25. The last sanitation inspection was conducted on 10/29/24 with three (3) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-olds is NC Foundations. Lead water testing, lead paint testing, and asbestos testing for this facility is not completed. Technical assistance, via email, was provided during today’s visit. Upon arrival, I introduced myself to Andrea Avery, Director. I observed the classroom of three and four-year-old children engaged in a group story time in the classroom. I observed the classroom of four, five, and six-year-old children having free choice on the playground. They were observed throwing frisbees, climbing, sliding, having dramatic play, running and interacting with each other and the caregivers. All interactions were positive and nurturing. Supervision was adequate. Three (3) emergency medications were monitored for child care requirements. The staff and training worksheets were received prior to today’s visit for monitoring. There is one (1) newly hired staff and nine (9) existing staff. The new staff’s file was monitored for child care requirements. One (1) existing staff’s file was monitored for child care requirements. Thirty-one (31) children are enrolled. Three (3) child files were monitored for child care requirements. The program does not provide transportation. St. Gerard House – The Grotto Therapeutic Center is occupying spaces #3, #4, #5, #6, and #7. These spaces were removed from Immaculata Pre-K approved spaces. A request for the facility's name to be changed to Immaculata Catholic Pre K has been submitted to DCDEE. There will be a reduction in capacity to 45 children based on the three toilets for children in spaces #1 and #2. The facility is located at a private school which has a second level. A restriction will be placed on the license to state children in care on ground level only. The facility is in the process of transitioning to a Notice of Compliance and operating under G.S. 110-106. A Letter of Intent must be completed by the Pastor. The Pastor must also complete the Division of Child Development and Early Education (DCDEE) Criminal Background Check application process and have a qualifying letter on file, as the Pastor would be considered the Legal Operator of a religious sponsored facility. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today's visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not posted in spaces #1 and #2. GS 110-91(12); .0508(a) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. The emergency medication, EPI Pen, in space #2 expired 11/2024. .0803(12) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. .1103(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .0514(g) Technical assistance provided as follows: 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS A current activity plan was not posted in spaces #1 and #2. A current activity plan was posted during the visit for correction. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The emergency medication, EPI Pen, in space #2 expired 11/2024. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES The staff files monitored today did not contain a signed and dated statement that they received a job description. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT Per the staff and training worksheets, one (1) staff, M.B. received zero (0) of the required five (5) hours of on-going training based on their education and experience. Achieving compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Signed statement of compliance I must receive your compliance statement by 6/5/2025. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary P.O. Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: Lead Paint and Asbestos Testing: In April 2023, North Carolina enacted final rules 10A NCAC 41C .1001-1007 requiring all public schools and child care facilities to: Test for lead in drinking/cooking water (.1005 and .2816), Identify lead-based paint hazards (.1004), Identify asbestos hazards (.1003), Mitigate or restrict access to any identified hazards. Testing is required to be completed by May 31, 2025. A flyer with step by step instructions was emailed to Ms. Avery during the visit. New and terminated staff notification requirement: As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0514 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0607 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0608 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0701 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0901 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1101 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2318 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2830 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/27/2024 Number Present: 28 Completed Date: 8/27/2024 Age: From 3 To 5 Total Minutes: 210 Time In: 10:00 AM Time Out: 01:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Unannounced Visit Follow-Up Announced/Unannounced: Unannounced Due to Consultant availability, today’s unannounced visit follow-up was made to monitor the completed staff and training worksheets and staff files that were unable to be monitored during the annual compliance visit on 8/19/24. A walk-through of the facility was conducted to monitor compliance of the violations documented on 8/19/24. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and signed by, Emily Kanipe, Program Manager, during the visit. A signed copy of the visit summary was left on-site for you. Emily Kanipe, Program Manager, was on-site to assist with the visit, provide documentation, ask and answer questions. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The staff and training worksheets were received during the annual compliance visit 8/19/24. The following violations, documented 8/19/24, requiring compliance, were monitored during today’s visit for compliance: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. Written permission for off-premise activities, including specific times of off-premise activities is in the process of being obtained. This violation is not currently in compliance. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. Mulch was delivered and installed for correction of this violation. 428- A current activity plan was not posted for each group of children for reference. Current activity plans were not posted in the preschool classrooms. This violation is not currently in compliance. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. One (1) preschool classroom’s activity plan did not include a daily gross motor activity which may occur indoors or outdoors. This violation is not currently in compliance. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. One (1) preschool classroom’s activity plan did not provide at least 4 different activities in art/creative play; books; blocks; manipulative; and dramatic play, including one of which is outdoors if weather conditions permit. This violation is currently not in compliance. 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. The medical action plan on file does not include the (f) manner in which the medication shall be administered or (i) the length of time authorization is valid. A revised medical action plan is in progress of being obtained. This violation is currently not in compliance. During today’s walk-through the children in the preschool classrooms were observed having free choice play outdoors and participating in special classes. The children in the Grotto space were observed having one-on-one learning experiences with the technicians. All interactions were positive, supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 862 The EMC plan was not reviewed with all staff annually and whenever the plan was revised. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. 10A NCAC 09 .0802(a) 1030 Application for employment and date of birth was not on file for all staff. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. .0302(d)(1)(A) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Staff E.K., hired 7/30/24 has a TB test on file dated 8/7/24. Staff D.S., hired 5/6/24, has a TB test on file dated 6/21/24. .0701(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. .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. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. .1101(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. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. .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. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. .1101(a)(b) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Per the staff and training worksheet, nine (9) staff do not have a current staff development plan or annual staff evaluation on file. 10A NCAC 09 .0514(f) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .0514(g) 1790 A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored today, per the children’s record form. .0901(d) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. Per the staff and training worksheet, eleven (11) staff have not reviewed the EPR plan annually. .0607(e) 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. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. .0608(d)(1-4) Technical assistance provided: 1034-All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Required for: All staff, including the director. Item Required: Health Questionnaire; a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Due Date: Annually following the initial medical statement. Nine (9) staff, per the staff and training worksheets, have expired health questionnaires. Plan to have staff update health questionnaires annually prior to expiration. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item Required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due Date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Nine (9) staff, per the staff and training worksheet, have expired Emergency Information forms. Plan to have staff complete an Emergency Information form on the first day of work and annually. 1045- New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 1067- Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS Each center shall ensure that each new employee who is expected to have contact with children receives 16 hours of on-site orientation within the first six weeks of employment. As part of this orientation, each new employee shall complete six hours of orientation within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete six clock hours in required training hours within the first two weeks of employment. One (1) staff, per the staff and training worksheet, did not complete sixteen clock hours in required training hours within the first six weeks of employment. Plan to use a calendar to schedule new hire orientation as required. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 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. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. One (1) staff, per the staff and training worksheet has CPR training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have CPR training. One (1) staff, per the staff and training worksheet has FA training form an unapproved training organization. One (1) staff, per the staff and training worksheet, hired, 5/6/24, does not have FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 1033- On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating they were free of active TB and/or TB test or screening was older than 12 months. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified Required for: All staff, including the director and individuals who volunteer more than once per week. Item: Tuberculin (TB) Test or Screening-The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Two (2) staff, per the staff and training worksheet did not have a TB test or screening on file, on or before the first day of work. Ensure future hires have a TB test or screening on file, on or before the first day of work. 1232-Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. Per the staff and training worksheet, eight (8) do not have a current annual staff evaluation. Per the staff and training worksheet, eight (8) do not have a current staff development plan or annual staff evaluation on file. Plan to use a calendar to ensure SDP and ASE are completed annually and do not lapse. 1824- The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (f) All staff shall review the center's Emergency Preparedness and Response Plan during orientation and on an annual basis with the trained staff. Documentation of the review shall be maintained at the center in the individual's personnel file or in a file designated for emergency preparedness and response plan documents. Per the staff and training worksheet, twenty (20) staff have not reviewed the EPR plan annually. Plan to use a calendar to plan the EPR review annually. 862- The EMC plan was not reviewed with all staff annually and whenever the plan was revised. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (a) Each child care center shall have a written plan that sets forth the steps to follow in the event of a child medical emergency. The plan shall be reviewed with all staff annually and whenever the plan is revised. This plan shall give the procedures to be followed to ensure that any child who becomes ill or is injured and requires medical attention while in care at the center receives appropriate medical attention. The following information shall be included in the center's emergency medical care plan: (1) The name of the person and at least one alternate, responsible for carrying out that plan of action, ensuring that appropriate medical care is given, and determining which of the following is needed: (A) first aid given at the center for an injury or illness needing only minimal attention; and (B) calling 911 in accordance with CPR or First Aid training recommendations. (2) The name of the person and one alternate, at the center responsible for: (A) ensuring that the signed authorization described in Paragraph (d) of this Rule is taken with the ill or injured child to the medical facility; (B) accompanying the ill or injured child to the medical facility; (C) notifying a child's parents or emergency contact person about the illness or injury and where the child has been taken for treatment; (D) obtaining substitute staff, if needed, to maintain required staff/child ratio and adequate supervision of children who remain in the center; and (3) A statement giving the location of the telephone located on the premises available for use in case of emergency. A telephone located in an office in the center that is sometimes locked during the time the children are present shall not be designated for use in an emergency. Per the staff and training worksheets, thirteen (13) staff have not reviewed the EMC plan annually. Plan to use a calendar to review the EMC annually. 1233- Each employee’s personnel file did not contain a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) New staff orientation shall include an overview of the following topics, focusing on the operation of the center: Review of the center's operational policies, including the center's safe sleep policy for infants, the center's policy for transportation, the center's identification of building and premises safety issues, the Emergency Preparedness and Response Plan, and the emergency medical care plan. Two (2) staff, per the staff and training worksheet, did not have a signed and dated statement that they received a job description and that they have reviewed personnel and operational policies. Plan to use a checklist to ensure all required documentation is on file for all staff. 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual's name; (2) the date the center's policy was given and explained to the individual; (3) the individual's signature; and (4) the date the individual signed the acknowledgment. The child care center shall retain the acknowledgement in the staff member's file. One (1) staff, per the staff and training worksheet, did not have documentation of the review of the shaken baby syndrome and abusive head trauma policy on file. Plan to use a checklist to ensure all required documentation is on file for all staff. 1030- Application for employment and date of birth was not on file for all staff. This violation was documented during the routine unannounced visit 3/6/24. This is a repeat violation. 10A NCAC 09 .2318 CHILD CARE CENTER RECORD RETENTION All records required in this Chapter shall be maintained for review by representatives of the Division as specified Type of Personnel Record: Application for Employment. One (1) staff, per the staff and training worksheet, did not have an application for employment on file. Plan to have all future potential staff, complete an application for employment and place on file. 1790- A statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not signed by the parent and/or maintained on file at the center. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (d) A child's parent may opt out of the supplemental food provided by the center as set forth in G.S. 110-91(2)h.1. When a child's parent opts out of the supplemental food provided by the center, the parent shall sign a statement acknowledging the parental decision shall be kept in the child's file at the center and a copy provided to the parent. A signed statement acknowledging the parental decision to opt out of the supplemental food provided by the center was not on file for the children’s files monitored 8/19/24, per the children’s record form. Plan to have all families complete and sign the nutritional opt-out form immediately and at enrollment. Achieving Compliance: A follow-up visit will be conducted to verify compliance of XXXX 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/10/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Excessive numbers of violations and repeat violations may initiate an administrative action. Consultation is provided as follows: Your compliance statement from the annual compliance visit on 8/19/24 is due 9/2/24. You stated CPR and FA training is scheduled 8/28/24 for staff. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0604 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0508 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0604 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0605 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0801 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0803 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1005 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1719 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2830 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

GS 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/19/2024 Number Present: 29 Completed Date: 8/19/2024 Age: From 3 To 5 Total Minutes: 220 Time In: 10:20 AM Time Out: 01:30 PM Time In: 02:30 PM Time Out: 03:00 PM List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Administrator, during the visit. Monica Houck, Lead Consultant, accompanied me on today’s visit. A signed copy of the visit summary was left on-site for you. Today, Andrea Avery, Administrator, and Emily Kanipe, Program Manager, accompanied us. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. We left the child care facility from 1:30pm to 2:30pm to complete the visit summary due to limited space. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-eight (88) percent as of 08/18/2024. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The approved curriculum for four-year-old children is NC Foundations. This program does not provide transportation. The last annual compliance visit was conducted on 8/22/23. The last fire drill was practiced on 7/31/24 The last shelter-in-place drill was practiced on 5/15/24 The last playground inspection was documented on 7/25/24 The last fire inspection was approved on 2/16/24 The last sanitation inspection was conducted on 2/20/24 with four (4) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The EPR plan was updated 8/29/23. Upon arrival We introduced our presence to the Administrator. A walk-through of the facility was conducted. The children in the Pre-k classrooms were observed having snack and small group activities. The children in the Grotto Therapeutic Center were observed having one-on-one learning with the Registered Behavior Technicians. The outdoor space allows for running, climbing, ball play, riding toys, sand, water, dramatic play and vigorous play. All interactions were positive. Supervision was adequate. There are (4) newly hired staff and nineteen (19) existing staff. The newly hired staff’s file and were (2) existing staff’s file was monitored for child care requirements. There are thirty (30) children enrolled. Four (4) child files were monitored for child care requirements. Due to time constraints, a return visit will be conducted to finalize the annual compliance visit. An annual compliance checklist will be completed and left on site for you upon completion of the return visit. Any violations documented during the return visit will be cited on today's annual compliance visit. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. A current activity plan was not available in space #1. GS 110-91(12); .0508(a) 431 The activity plan did not provide at least 4 different activities daily listed in GS 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. The activity plan in space #2 did not provide the required activities daily. .0508(g)(2) 523 The activity plan did not include a daily gross motor activity which may occur indoors and outdoors. The activity plan in space #2 did not include daily gross motor activity. .0508(g)(3) 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. .0605(j) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. 10A NCAC 09 .0604(c) 825 Before staff members walked children off premises for play or outings, the center did not obtain written permission from the parent of each child. One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. .1005(b)(3) 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. Glass cleaner and batteries were stored in unlocked storage in space #2. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 15A NCAC 18A .2820(d) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. .0803(12) 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. A medical action plan was not on-site for the EPI pen in space #1. .0801(b) Technical assistance was provided as follows: 825 - One (1) child participated in an off-premise activity to take a walk outside at the front of the building at the sidewalk and grassy area with a caregiver today. There was not written permission from the parent of the child to go outside and take a walk outside at the front of the building at the sidewalk and grassy area. 10A NCAC 09 .1005 OFF PREMISE ACTIVITIES IN CHILD CARE CENTERS (b) When children participate in off premise activities the following shall apply: (1) Children under the age of three shall not participate in off premise activities that involve children being transported in a motor vehicle. (2) When children are transported in a motor vehicle for off premise activities, the provisions in Rule .1003(c) through (i) and (k) of this Chapter shall apply. (3) Before staff members walk children off premises for play or outings, the center shall obtain written permission from the parent of each child to be included in such activities. (4) Parents may provide a written statement giving standing permission which may be valid for up to 12 months for participation in off premise activities that occur on a regular basis. (5) The center shall post a schedule of off premise activities in each participating classroom where it can be viewed by parents, and a copy shall be given to parents. The schedule shall be current and shall include the: (A) location of the activity; (B) purpose of the activity; (C) time the activity will take place; (D) date of the activity; and (E) name of the person(s) to be contacted in the event of an emergency. (6) Each time that children are taken off the premises, staff shall take a list of the children participating in the activity with them. Staff members shall use this list to check attendance when leaving the center, periodically when the children are involved in the activity, before leaving the activity to return to the child care center, and upon return to the center. A list of all children participating in the off premise activity shall also be available at the center. 716 - The stationary equipment in outdoor space #1 had less than one (1) inch of mulch protective surfacing. 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) 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; 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. 10A NCAC 09 .1719 REQUIREMENTS FOR A SAFE INDOOR/OUTDOOR ENVIRONMENT (7) keep all corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product that is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled shall be kept in its original container or in another labeled container, used according to the manufacturer's instructions, and stored in a locked area when not in use. Locked areas shall include those that are unlocked with a combination, electronic, or magnetic device, key, or equivalent locking device. These unlocking devices shall be kept out of the reach of a child and shall not be stored in the lock. Toxic substances shall be stored below or separate from medications and food. Any product not listed in this Paragraph that is labeled "keep out of reach of children" without any other warnings shall be kept inaccessible to children when not in use, but is not required to be kept in locked storage. The product shall be considered inaccessible to children when stored on a shelf or in an unlocked cabinet that is mounted a minimum vertical distance of five feet above the finished floor. Glass cleaner and batteries were stored in unlocked storage in space #2. The cabinet was locked during the visit for correction. No further action is required. 812-Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (c) When not in use, electrical outlets and power strips located in space used by children shall have safety outlets or be covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In space #2, a power strip on the counter had uncovered outlets. In space #1, an outlet on the far wall, under the window was uncovered. Safety plugs were inserted for correction during the visit. No further action is required. 849-Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. One (1) over the counter medication, New Skin Liquid Bandage Spray, on-site, expired 7/31/24. One (1) prescription medication, Mupirocin, on-site, expired 09/2023. Both medications were removed during the visit for correction. No further action is required. 841-Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be stored out of reach of children but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept out of reach of children when not in use but are not required to be in locked storage. One (1) prescription medication, Mupirocin, was stored unlocked in the restroom of the Grotto Therapeutic Center. One (1) over the counter medication, New Skin Liquid Bandage Spray, with numerous warnings, was stored unlocked in the Grotto Therapeutic Center’s restroom. The medication was removed for correction during the visit. No further action is required. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (1) No prescription or over-the-counter medication and no topical, non-medical ointment, repellent, lotion, cream, fluoridated toothpaste, or powder shall be administered to any child: (a) without written authorization from the child's parent; (b) without written instructions from the child's parent, physician or other health professional; (c) in any manner not authorized by the child's parent, physician or other health professional; (d) after its expiration date; (e) for non-medical reasons, such as to induce sleep; or (f) with a known allergy to the medication. (2) Prescribed medications: (a) shall be stored in the original containers in which they were dispensed with the pharmacy labels; (b) if pharmaceutical samples, shall be stored in the manufacturer's original packaging, shall be labeled with the child's name, and shall be accompanied by written instructions specifying: (i) the child's name; (ii) the names of the medication; (iii) the amount and frequency of dosage; (iv) the signature of the prescribing physician or other health professional; and (v) the date the instructions were signed by the physician or other health professional; (c) shall be administered only to the child for whom they were prescribed; and (d) shall be administered according to the prescription, using amount and frequency of dosage specified on the label. (3) A parent's written authorization for the administration of a prescription medication described in Item (2) of this Rule shall be valid for the length of time the medication is prescribed to be taken. (4) Over-the-counter medications, such as cough syrup, decongestant, acetaminophen, ibuprofen, topical antibiotic cream for abrasions, or medication for intestinal disorders shall be stored in the manufacturer's original packaging on which the child's name is written or labeled and shall be accompanied by written instructions specifying: (a) the child's name; (b) the names of the authorized over-the-counter medication. (c) the amount and frequency of the dosages, which shall not exceed the amount and frequency of the dosages on the manufacturer's label; (d) the signature of the parent, physician or other health professional; and (e) the date the instructions were signed by the parent, physician or other health professional. The permission to administer over-the-counter medications is valid for up to 30 days at a time, except as allowed in Items (6), (7), (8) and (9) of this Rule. Over-the-counter medications shall not be administered on an "as needed" basis, other than as allowed in Items (6), (7), (8) and (9) of this Rule. 428- A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. A current activity plan was not available in space #1. Plan to ensure staff post a current activity plan for each week. 431-The activity plan did not provide at least 4 different activities daily listed in G.S. 110-91(12): art/creative play; books; blocks; manipulatives; and family living and dramatic play, including one of which is outdoors if weather conditions permit. 523-The activity plan did not include a daily gross motor activity which may occur indoors or outdoors. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (b) For each group of children in care, the activity plan shall include activities intended to stimulate the following developmental domains, in accordance with North Carolina Foundations for Early Learning and Development, available on the Division's website at http://ncchildcare.nc.gov/providers/pv_foundations.asp: (1) emotional and social development; (2) health and physical development; (3) approaches to play and learning; (4) language development and communication; and (5) cognitive development. (c) When children are in care and weather conditions permit, there shall be outdoor time, either as part of a small group, a whole group, or individual activity, for no less than the following durations: Children ages 2-12 years; Minimum daily outdoor time: 60 minutes. (g) The activity plan shall: (1) identify activities that allow children to choose to participate with the whole group, part of the group, or independent of the group; (2) reflect that the children have four different activities daily, at least one of which is outdoors, if weather conditions permit, as listed in G.S. 110-91(12) as follows: (A) art and other creative play; (B) children's books; (C) blocks and block building; (D) manipulatives; and (E) family living and dramatic play; and (3) include a daily gross motor activity that may occur indoors or outdoors. The activity plan, posted in space #2, did not meet the requirements listed above. Plan to train staff on the requirements of activity plans. 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. 10A NCAC 09 .0801 APPLICATION FOR ENROLLMENT (b) For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan shall be completed by the child's parent or a health care professional and may include the following: (1) a list of the child's diagnosis or diagnoses including dietary, environmental, and activity considerations that are applicable; (2) contact information for the child's health care professional(s); (3) medications to be administered on a scheduled basis; and (4) medications to be administered on an emergency basis with symptoms, and instructions. The medical action plan shall be updated on an annual basis and when changes to the plan are made by the child's parent or health care professional. A medical action plan was not on-site for the EPI pen in space #1. Plan to obtain a completed medical action plan immediately. Achieving Compliance: 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. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. 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. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/2/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828.556.3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0302 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0803 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2510 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2830 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2902 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-105 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-90 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 32 Completed Date: 3/6/2024 Age: From 0 To 6 Total Minutes: 270 Time In: 10:30 AM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of this routine unannounced visit was to conduct limited compliance monitoring and offer consultation to the program. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Director, during the visit. A signed copy of the visit summary was left on site for you. Upon arrival, I made my presence known to Andrea Avery, Director. Ms. Avery was available to assist during the visit. Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The following areas were monitored: Supervision Ratios CPR First Aid Criminal Record Checks Emergency Medical Care Plan Administration of Medication Storage of Hazardous Substances Storage of Medication Adequate/Approved Space General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were participating in free choice play indoors and gross motor play indoors due to inclement weather. All interactions were positive and nurturing. Supervision was adequate. There are ten (10) newly hired staff. A staff and training worksheet for the newly hired staff was completed during the visit. The ABCMS system was checked for all staff members. All staff members have valid criminal background letters. The developmental day requirements in section .2900 of the childcare rules were monitored for compliance. Children who receive developmental day services are currently cared for in spaces #1 and #2. Staff-child ratios and maximum group sizes required in Child Care Rule 10A NCAC 09 .2902(f) were verified in compliance. Lead teachers assigned to each of these spaces have NC Birth-through-Kindergarten licenses and both administrators have a Level III NCECAC with over five years’ experience. The program operates seven hours per day, Monday through Friday, ten months per year. Children’s individual plans for care and developmentally appropriate activity plans are followed, and opportunities for inclusion with children who are typically developing are offered. I confirmed this facility provides the following five family involvement activities: (1) quarterly parent education sessions, (2) parent/teacher conferences twice a year; (3) daily notes of progress provided to parents; (4) opportunities for parent volunteers to assist with special classroom activities, field trips and other learning experiences for children; (5) and provides parents with referral information about other community programs and resources serving young children. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit. Violation Number Comment Rule 1030 Application for employment and date of birth was not on file for all staff. One staff, per the staff and training worksheets, did not have an application on file. .0302(d)(1)(A) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(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. Four staff, per the staff and training worksheets, do not have current FA training. .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. our staff, per the staff and training worksheets, do not have current CPR training. .1102(d) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. .1101(a)(b) 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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. .1102(g) Technical assistance was provided as follows: #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, per the staff and training worksheets, did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Plan to have the staff complete the training. Plan to use calendar reminders of the 90 day due dates to ensure the required training is completed. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. #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. #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. Four staff, per the staff and training worksheets, do not have current CPR and FA training. Plan to use calendar reminders of the 90 day due dates and expiration dates of each staff’s CPR and FA trainings. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (c) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in First Aid appropriate to the ages of children in care. The training shall be completed by June 30, 2018, or for new staff hired on or after September 1, 2017, training must be completed within 90 days of employment. Distance learning shall not be permitted for First Aid training. At all times when children are in care at least one staff member present must have successfully completed First Aid training, as evidenced by a certificate or card from an approved training organization. First Aid training shall be renewed on or before expiration of the certification. "Successfully completed" is defined as demonstrating competency, as evaluated by the instructor. Verification of each required staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp. (d) All staff who provide direct care or accompany children when they are off premises shall successfully complete certification in a cardiopulmonary resuscitation (CPR) course appropriate to the ages of children in care. At all times when children are in care one staff member present must have successfully completed CPR training. The training shall be completed by June 30, 2018 or for new staff hired on or after September 1, 2017 training must be completed within 90 days of employment. Distance learning shall not be permitted for CPR training. CPR training shall be renewed on or before the expiration of the certification. Verification of each staff member's completion of this course from an approved training organization shall be maintained in the staff member's file in the center. The Division shall post a list of approved training organizations on its website at http://ncchildcare.nc.gov/providers/pv_sn2_ov_pd.asp #1030 Application for employment and date of birth was not on file for all staff. 10A NCAC 09 .0302 APPLICATION FOR A LICENSE FOR A CHILD CARE CENTER (1) staff records that include: (A) an application for employment and date of birth. One staff, per the staff and training worksheets, did not have an application on file. Plan to have all staff complete an application prior to hire. #1045 and #1067 New staff who have contact with children, did not receive at least 16 hours of orientation within first 6 weeks. Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. There was no documentation of orientation for one staff, per the staff and training worksheets. Plan to provide orientation for the staff member and designate time within the first two and six weeks of new hires to complete orientation and document accordingly. 10A NCAC 09 .2510 STAFF QUALIFICATIONS (1) Within the first two weeks of assuming responsibility for supervising a group of children, each employee shall complete at least six clock hours of training on: (A) recognizing, responding to, and reporting child abuse, neglect or maltreatment pursuant to G.S. 110-105.4 and G.S. 7B-301; (B) the center's operational policies, including the transportation policy, identification of building and premises safety issues, Emergency Preparedness and Response Plan and the emergency medical care plan; (C) adequate supervision of children, taking into account their age, emotional, physical, and cognitive development; and (D) prevention and control of infectious diseases, including immunization; and (2) Within the first six weeks of assuming responsibility for supervising a group of children, each employee shall complete at least three additional clock hours of training on: (A) maintaining a safe and healthy environment and developmentally appropriate activities for school-age children; (B) firsthand observations of the program's daily operations and instruction in the employee's assigned duties; (C) instruction in the administration of medication to children in accordance with 10A NCAC 09 .0803; (D) successfully complete CPR and First Aid training appropriate for the ages of children in care; (E) prevention of and response to emergencies due to food and allergic reactions; (F) review of the program's handling and storage of hazardous materials and the appropriate disposal of biocontaminants; and (G) review of child care licensing law and rules, including an explanation of the role of State and local government agencies in the regulation of child care and the employee's obligation to cooperate with representatives of State and local government agencies during visits and investigations. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation is provided as follows: Per your request, information pertaining to record retention will be emailed to you. Challenging Behaviors Helpline: The Division has established a challenging behaviors helpline. If you would like resources for behavioral management, please contact the helpline at 1-888-600-1685 Option 1. Dawn McCrary provided you with a hard copy handout with the information for the challenging behaviors helpline. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify me, may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0302 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0304 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0508 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0514 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0601 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0604 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0608 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .0701 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1102 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .1703 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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 .2830 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-90 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

G.S. 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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

GS 110-91 · Violation

Name of Operation: IMMACULATA CATHOLIC PreK Facility ID: 4555078 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 8/22/2023 Number Present: 31 Completed Date: 8/22/2023 Age: From 3 To 5 Total Minutes: 390 Time In: 09:15 AM Time Out: 03:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Dawn McCrary, Child Care Consultant and also signed by Andrea Avery, Pre-K Director, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Andrea Avery, Pre-K Director. Ms. Avery assisted during the visit. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety (90) percentage as of 8/21/2023 Permit type – Five Star Child Care License, issued 2/19/20, earning six points for staff education, seven points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meeting reduced ratios; Meets enhanced space. The last annual compliance visit was conducted on 9/1/22 The last fire drill was practiced on 7/19/23 The last shelter-in-place drill was practiced on 3/23/23 The last playground inspection was documented on 7/27/23 The last fire inspection was approved on 3/24/23 The last sanitation inspection was conducted on 2/21/23 with six (6) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was updated 12/12/22. The approved curriculum for four-year-old children is NC Foundations During the walk-through monitoring, the children were observed having a large group music activity, free choice play and routine care. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for climbing, balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. All interactions were positive and nurturing. Supervision was adequate. Thirty-two (32) children are enrolled. Three (3) children’s files were monitored for child care requirements. There are eleven (11) newly hired staff. The newly hired staff files and two (2) existing staff files were monitored for child care requirements. The staff and training worksheet was available, partially updated, and partially monitored during today’s visit. Due to the accessibility of various staff file information, and Ms. Avery's afternoon duties, a return visit will be conducted to monitor staff requirements and the outdoor learning environments. Any additional violations will be documented on a visit addendum. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in space #1. GS 110-91(12); .0508(a) 721 All equipment and furnishings were not in good repair. The carpet to the entrance to space #6 was frayed approximately three inches deep, completely across the entrance. The carpet was taped to cover the fraying during the visit for repair. A piece of the plastic fall zone barrier on the playground has a crack large enough for a hand or foot to be inserted. Nails are beginning to be exposed on the border around the tree on the playground. A board along the walkway is rotting and splintering. G.S. 110-91(6); .0601(b) 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. Staff J.N.; C.R.; A.W.; and L.P. did not have the required Emergency Information form on file on or before the first day of work. .0701(a) 1232 Each employee's personnel file did not contain an annual staff evaluation and a staff development plan. Staff S.G, G.C. and R.S. do not have a current annual staff evaluation and staff development plan on file. 10A NCAC 09 .0514(f) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill was practiced 3/23/23. .0604(u);.0302(d)(8) 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. Staff A.A., hired 9/15/22, reviewed and signed this policy 10/14/22. .0608(d)(1-4) 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. Staff P.C., hired 8/25/21 as a substitute, has subbed greater than 10 days in 12 months and has not completed this training. Staff M.C., hired 8/30/22 has not completed this required training. .1102(g) 1898 Staff did not complete the health and safety training within one year of employment. Staff P.C. hired as a substitute 8/25/21, has subbed more than 10 days in 12 months, has not completed this training. .1102(a) Technical assistance provided 721 All equipment and furnishings were not in good repair. 10A NCAC 09 .0601 SAFE ENVIRONMENT (b) All equipment and furnishings shall be in good repair. All commercially manufactured equipment and furnishings shall be assembled and installed according to procedures specified by the manufacturer. For equipment and furnishings purchased after September 1, 2017, the manufacturer's instructions shall be kept on file or electronically accessible, if available. 428 A current activity plan was not posted for each group of children for reference. 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS (a) All centers shall have a current schedule and activity plan for each group of children posted for reference by parents and by caregivers. The schedule and activity plan may be combined in a single document. 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). 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. 10A NCAC 09 .0608 PREVENTION OF SHAKEN BABY SYNDROME AND ABUSIVE HEAD TRAUMA (d) Within 30 days of adopting the policy, the child care center shall review the policy with existing staff members who provide care for children up to five years of age. Each child care center shall review the policy with new staff members prior to the individual providing care to children. The acknowledgement of this review shall contain: (1) the individual’s name; (2) the date the center’s policy was given and explained to the individual; (3) the individual’s signature; and (4) the date the individual signed the acknowledgment. 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. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified: Required for: Child care providers, including the director, uncompensated providers, substitute providers, and volunteers. Item required: Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional. Due date: On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. 1898 Staff did not complete the health and safety training within one year of employment. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (a) Child care administrators and staff members shall complete health and safety training within one year of employment, unless the staff member has completed the training within the year prior to beginning employment. Health and safety training shall be in addition to the new staff orientation requirements set forth in Rule .1101 of this Section. #1232 Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (f) In addition to all records required in Rule .0302(d) of this Chapter, each employee's personnel file shall contain an annual staff evaluation and staff development plan. 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. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Corrective Action Plan: All violations are required to be corrected immediately. However, if at any time you are unable to correct all violations within the specified time frame, please send a written statement regarding those violations that were corrected and include a specific plan for correction of the remaining violations. Please be aware that any written information submitted by you regarding correction of violations documented during today’s visit would be considered as legal documentation. Therefore, it is important that all information submitted be accurate and truthful. Please be aware that if it is determined that information submitted was inaccurate or willfully falsified, an Administrative Action, including Revocation of the facility’s license may be issued. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/5/23. Email the compliance letter on signed letterhead or on the email identifying your facility name, ID#, name and position to: dawn.mccrary@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Dawn McCrary PO Box 397 Penrose, NC 28766 Please call me at 828-556-3088, or email dawn.mccrary@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Falsification of any information may result in a revocation of your license. You must maintain at least 75% Compliance History for each 18-month period as required by G.S. 110-90(4) (c). Please note any violations cited today and during future visits will negatively impact your compliance history. Repeated violations or violations left unresolved may lead to an administrative action. Consultation Staff B.S. must complete 11.75 hours of on-going training by 9/13/23 Staff S.F. must complete 2 hours of on-going training by 8/30/23 Staff M.C. must complete health and safety training by 8/30/23 If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at dawn.mccrary@dhhs.nc.gov or 828-556-3088, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@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