MT. Pisgah Lutheran Preschool

10A NCAC 09 .0304 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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 .3222 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 6/29/2026 Number Present: 43 Completed Date: 6/29/2026 Age: From 0 To 10 Total Minutes: 295 Time In: 09:30 AM Time Out: 02:25 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Admin, during the visit. A signed copy of the visit summary was left on-site for you. Candace Fisher, Admin, greeted me upon arrival and assisted me today. 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. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The center’s compliance history was reviewed with the operator. The program’s compliance history is eighty-eight percent (88%) as of 6/28/26. The last annual compliance visit was conducted on 7/2/2025. The last fire drill was practiced on 5/28/2026. The last lockdown drill was practiced on 5/28/2026. The last playground inspection was documented on 5/29/2026. The last fire inspection was approved on 6/11/2025. The last sanitation inspection was conducted on 1/22/2026 with six (6) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The approved curriculum for four-year-old children is Creative Curriculum. The water lead testing was completed on 9/25/25, with no hazards found. During today’s visit, the infants were moving freely on the floor of the classroom and interacting with their caregivers and toys. The children in the classroom of one-year-olds were having free choice play on the playground and transitioned indoors for routine care and to eat. The children in the classroom of one and two-year-olds were having free choice play on the playground, and transitioned indoors for routine care and lunch. The children in the classroom of two and three-year-olds were having free choice play on the playground and transitioned indoors to wash hands and participate in a large group activity. The children in the classroom of four to ten-year-olds were having free choice play in their classroom. The lunch served today was black beans, mixed vegetables, salsa, tortilla, and milk 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 was dated 6/11/2025. 10A NCAC 09 .0304(a) 721 All equipment and furnishings were not in good repair. The large playground has several areas of chipping and peeling paint. G.S. 110-91(6); .0601(b) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025. .0701(a) 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) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas 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. One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025. 10A NCAC 09 .0514(f) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics. .1103(b) Technical assistance provided as follows 10A NCAC 09 .0304 ON-GOING REQUIREMENTS FOR A LICENSE (a) 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. To come into compliance, Ms. Fisher stated she will contact the fire marshal to obtain a fire inspection, and will place a reminder on her calendar to schedule a fire inspection prior to the current one expiring. 10A NCAC 09 .1101 NEW STAFF ORIENTATION REQUIREMENTS (a) 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. To come into compliance, Ms. Fisher stated she will complete the orientation training with the newly hired employee and place reminders on a calendar to complete the remaining orientation training on time. 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 below: 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. On or before the first day of work. The emergency information shall be updated as changes occur and at least annually. Health Questionnaire, a statement signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. To achieve compliance, the health questionnaire and emergency information form will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 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. To achieve compliance, the annual staff evaluation and staff development plan will be completed and a reminder will be put on the calendar for each employee's date to complete the required forms. 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT (a) After the first year of employment, the child care administrator and any staff who have responsibility for planning and supervising a child care center, and staff who work with children, shall participate in on-going training activities annually, as follows: (b) Health and safety training shall be completed as part of on-going training so that every five years, all of the topic areas set forth in 10A NCAC 09 .1102(b) will have been covered. To achieve compliance, the health and safety trainings will be completed and a reminder will be put on the calendar for each employee's date to complete the required trainings. 10A NCAC 09 .0601 SAFE ENVIRONMENT (a) All child care centers shall provide a safe indoor and outdoor environment for the children in care. (c) Equipment and furnishings shall be sturdy, stable, and free of hazards that may injure children including sharp edges, lead based or peeling paint, rust, loose nails, splinters, protrusions (excluding nuts and bolts on sides of fences), and pinch and crush points. We discussed having the peeling paint areas sanded and painted. Ms. Fisher stated she would contact the church to schedule the repairs. Ms. Fisher stated that moving forward, any needed repairs will be scheduled as the playground inspection is completed. 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 7/13/2026. 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: Plan to practice a fire drill by 6/30/2026. Plan to conduct a playground inspection by 6/30/2026. We discussed several staff have upcoming CPR/FA trainings scheduled as their previous training expires soon. We discussed printing the updated EPR plan and reviewing with all staff. We discussed that technical assistance from DCDEE has been requested to assist with the ABCMS facility roster. 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 .3222 (c) If employment-related changes occur at a facility that result in noncompliance with or failure to meet the standards in the Section for the star rating issued, the operator shall correct the noncompliance within six months. If the operator does not correct the noncompliance within six months, 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.your.number, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: LORI HERRICK Operation Type: Center Case Number: 0326-436A Visit Date: 3/31/2026 Number Present: 55 Completed Date: 3/31/2026 Age: From 0 To 5 Total Minutes: 345 Time In: 10:15 AM Time Out: 04:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of this unannounced visit was to investigate allegations of violations of childcare requirements at this childcare facility. Candace Fisher, Admin Tech, was on site. Ms. Fisher accompanied me during a walk-through of the facility. During the visit, I discussed the allegations with Ms. Fisher and additional staff members. Limited monitoring of child care requirements occurred during today’s visit. Violation Number Comment Rule 303 Children were not adequately supervised at all times. On March 25, 2026, a staff member was seated on a crate and was not providing adequate supervision for one- and two-year-old children. Another staff member was not immediately aware when a four-year-old child exited the fenced playground and ran towards a highway. .1801(a)(1-5) 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. On March 25, 2026, a four-year-old child was grouped with one and two-year-old children on the playground for approximately thirty minutes. 10A NCAC 09 .0713(a)(6) 807 A safe indoor and outdoor environment was not provided for the children. A staff member failed to ensure a safe environment for children when a four-year-old child exited the playground and entered a busy road causing cars to stop before the staff member retrieved the child. 10A NCAC 09 .0601(a) 1810 There was a substantiation of child maltreatment. The Division confirmed sufficient information to determine child maltreatment based on supervision needs of children. GS 110-105.6(a) You may contact me at Lori Herrick, Investigations Consultant, 828-782-0613, lori.herrick@dhhs.nc.gov. or Natosha Lambeth, Natosha.lambeth@dhhs.nc.gov Thank you for your time. 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 .0713 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: LORI HERRICK Operation Type: Center Case Number: 0326-436A Visit Date: 3/31/2026 Number Present: 55 Completed Date: 3/31/2026 Age: From 0 To 5 Total Minutes: 345 Time In: 10:15 AM Time Out: 04:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of this unannounced visit was to investigate allegations of violations of childcare requirements at this childcare facility. Candace Fisher, Admin Tech, was on site. Ms. Fisher accompanied me during a walk-through of the facility. During the visit, I discussed the allegations with Ms. Fisher and additional staff members. Limited monitoring of child care requirements occurred during today’s visit. Violation Number Comment Rule 303 Children were not adequately supervised at all times. On March 25, 2026, a staff member was seated on a crate and was not providing adequate supervision for one- and two-year-old children. Another staff member was not immediately aware when a four-year-old child exited the fenced playground and ran towards a highway. .1801(a)(1-5) 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. On March 25, 2026, a four-year-old child was grouped with one and two-year-old children on the playground for approximately thirty minutes. 10A NCAC 09 .0713(a)(6) 807 A safe indoor and outdoor environment was not provided for the children. A staff member failed to ensure a safe environment for children when a four-year-old child exited the playground and entered a busy road causing cars to stop before the staff member retrieved the child. 10A NCAC 09 .0601(a) 1810 There was a substantiation of child maltreatment. The Division confirmed sufficient information to determine child maltreatment based on supervision needs of children. GS 110-105.6(a) You may contact me at Lori Herrick, Investigations Consultant, 828-782-0613, lori.herrick@dhhs.nc.gov. or Natosha Lambeth, Natosha.lambeth@dhhs.nc.gov Thank you for your time. 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 110-105 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: LORI HERRICK Operation Type: Center Case Number: 0326-436A Visit Date: 3/31/2026 Number Present: 55 Completed Date: 3/31/2026 Age: From 0 To 5 Total Minutes: 345 Time In: 10:15 AM Time Out: 04:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of this unannounced visit was to investigate allegations of violations of childcare requirements at this childcare facility. Candace Fisher, Admin Tech, was on site. Ms. Fisher accompanied me during a walk-through of the facility. During the visit, I discussed the allegations with Ms. Fisher and additional staff members. Limited monitoring of child care requirements occurred during today’s visit. Violation Number Comment Rule 303 Children were not adequately supervised at all times. On March 25, 2026, a staff member was seated on a crate and was not providing adequate supervision for one- and two-year-old children. Another staff member was not immediately aware when a four-year-old child exited the fenced playground and ran towards a highway. .1801(a)(1-5) 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. On March 25, 2026, a four-year-old child was grouped with one and two-year-old children on the playground for approximately thirty minutes. 10A NCAC 09 .0713(a)(6) 807 A safe indoor and outdoor environment was not provided for the children. A staff member failed to ensure a safe environment for children when a four-year-old child exited the playground and entered a busy road causing cars to stop before the staff member retrieved the child. 10A NCAC 09 .0601(a) 1810 There was a substantiation of child maltreatment. The Division confirmed sufficient information to determine child maltreatment based on supervision needs of children. GS 110-105.6(a) You may contact me at Lori Herrick, Investigations Consultant, 828-782-0613, lori.herrick@dhhs.nc.gov. or Natosha Lambeth, Natosha.lambeth@dhhs.nc.gov Thank you for your time. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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 .0701 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 52 Completed Date: 7/2/2025 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by Candace Fisher, Administration, during the visit. An electronic signed copy of the summary was left on-site. Today, Candace Fisher, Administration, was available to assist 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-two (92) percentage as of 7/1/25. Permit type- Four Star Child Care License; issued 1/31/2020; earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions- Daytime care only, Meets enhanced ratios; Meets enhanced space. The last annual compliance visit was conducted on 7/11/24. The last fire drill was practiced on 5/7/25. The last lockdown drill was practiced on 5/20/25. The last playground inspection was documented on 6/30/25. The last fire inspection was approved on 6/11/25. The last sanitation inspection was conducted on 6/12/25 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The curriculum for four-year-old children is Creative Curriculum. During today’s visit, the children in the infant room were on the floor with their caregiver, interacting and moving freely. The children in the classroom of one-year-olds were having free choice play on the playground. The children in the two-year-old classroom, and the classrooms of two and three-year-old children were having free choice play on the playground. The children in the three to five-year-old classrooms were having free choice play indoors. The classrooms alternated outdoor play. The younger children transitioned indoors earlier than the older children to wash hands for lunch. The lunch served today was turkey, bread, corn, black beans, salsa and milk. the All interactions were positive. Supervision was adequate. There are sixty-one (61) children enrolled. Six (6)child files were monitored for child care requirements. There are five (5)newly hired staff and nine existing staff. The newly hired staff files and one existing staff file were monitored for child care requirements. The program does not provide transportation. 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 with the end date of 6/30/25 was posted in the classroom of two year-olds. GS 110-91(12); .0508(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 10A NCAC 09 .0701(a) Technical assistance provided as follows: #428 10A NCAC 09 .0508 ACTIVITY SCHEDULES AND PLANS An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds. A current activity plan was posted for correction during the visit. #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24. 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 7/16/25. 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. New and terminated staff notification requirement: (Remove if training was completed and ABCMS portal has been updated.) 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. 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 was required to be completed by May 31, 2025. You stated that you have been in communication with environmental health concerning the testing. Consultation provided as follows: We discussed the fire inspection requirements, details follow below in this consultation section. We discussed that you are aware that staff T.C. and T.L. have CPR and FA training that expires 7/14/25 and staff S.M., C.S., and K.S. have CPR and FA training that expires 10/16/25. We discussed that I will email record retention rules to 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2025 Number Present: 62 Completed Date: 2/21/2025 Age: From 0 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: 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, printed, and signed by me, Dawn McCrary, Child Care Consultant, and you, Joyce McAbee, Director, during the visit. A signed copy of the visit summary was left on site for your records. Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. Upon arrival, I made my presence known to Joyce McAbee, Director. Ms. McAbee was 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 ITS SIDS requirements General Safety Discipline Program Records License Posted/ Permit Restrictions. During today’s visit, the children were having free choice play in the classrooms. Due to frigid temperatures, gross motor activities took place indoors. The children transitioned to lunch. The outdoor play area offers adequate space for running and vigorous play with opportunities to climb, balance, ride toys, participate in dramatic play and sand and water play. All interactions were positive. Supervision was adequate. There are (5) newly hired staff. The newly hired staff files were monitored for child care requirements. All staff have valid criminal background letters. This program does not provide transportation. 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 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. Staff M.H. does not have current First Aid 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. Staff M.H. does not have current CPR training. .1102(d) Technical assistance provided as follows: 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS Staff M.H. does not have current CPR and FA training. Plan to have M.H. complete the trainings immediately. Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency. Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance. 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 3/7/25. 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: QRIS Modernization: We discussed the proposed QRIS Modernization system. The public comment period is now open. Plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the proposed Pathways. You can submit any comments to the following contact: Child Care Commission 2201 Mail Service Center Raleigh, NC 27699-2201 Attn: Julie Peck 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. 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) 814-8401 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/11/2024 Number Present: 35 Completed Date: 7/11/2024 Age: From 0 To 5 Total Minutes: 300 Time In: 09:30 AM Time Out: 02:30 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 me, Dawn McCrary, Child Care Consultant and also signed by you, Katherine Montgomery, Director. A signed copy of the visit summary was left on-site for you. Today, Katherine Montgomery, Director, was available to assist 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-six (96) percentage as of 7/10/24. Currently this center operates with a Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The Secretary of State website was reviewed today, and the Non-Profit Corporation, Mt. Pisgah Lutheran Church of Henderson County, Inc., is listed as active-current. If any changes to the organization need to be made or you decide to sell your business, then you must notify your consultant at least thirty (30) days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location or inherited. The last Annual Compliance visit was conducted on 7/20/23. The last fire drill was practiced on 6/28/24. The last lockdown drill was practiced on 5/31/24. The last playground inspection was documented on 6/28/24. The last fire inspection was approved on 7/10/24. The last sanitation inspection was conducted on 6/14/24 with five (5) demerits for a Superior classification. The Emergency Medical Care plan was posted and is current. The Emergency Preparedness Plan is current. The incident log was current and in use. The curriculum for four-year-old children is Creative Curriculum. Upon my arrival, I made my presence known to Katherine Montgomery, Director. The infants were observed sleeping, drinking a bottle and having diapers changed. The one and two-year-old children were observed having free choice play on the playground and transitioning indoors to the classroom. Indoors, the one and two-year-old children were observed having free choice play in the classroom. The two and three-year-old children were observed having free choice play on the playground. The four and five-year-old children were observed cleaning up after free choice play and preparing for lunch. The outdoor playground offers many opportunities for running and vigorous play. The equipment provides opportunities for balancing, riding toys, ball play, sand and water and dramatic play. Portable materials were available to enhance outdoor play. The lunch served today was garbanzo beans, corn, tomatoes, cucumbers, tortillas and milk. All interactions were positive and nurturing. Supervision was adequate. Forty-six (46) children are enrolled. Five (5) children’s files were monitored for child care requirements. There are five (5) newly hired staff and eight (8) existing staff. The five (5) newly hired staff files, and one (1) existing staff file, were monitored for child care requirements. The staff and training worksheet was provided and monitored during today’s visit. This program does not provide transportation. 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 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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. .0803(12) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas. .1101(a) 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, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas. .1101(a)(b) Technical assistance provided: #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 on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024. 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS The following provisions apply to the administration of medication in child care centers: (12) Any medication remaining after the course of treatment is completed, after authorization is withdrawn or after authorization has expired shall be returned to the child's parents. Any medication the parent fails to retrieve within 72 hours of completion of treatment, or withdrawal of authorization, shall be discarded. Plan to send the expired medication home with the child's parent today. Plan to monitor medications monthly for expirations. #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. One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of training in required topic areas, nor the sixteen required hours of orientation within the first six weeks of employment. Plan to have the staff in question, complete orientation immediately. Plan to designate time within the first two and six weeks of hire 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: 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 7/25/24. 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: You stated that you are aware of the upcoming CPR and FA trainings that are expiring soon. If you elect to change and/or alter any previously approved spaces used by children as indicated on the 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 828-566-3088, 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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 .0302 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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 .0604 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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 .0701 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 2/21/2024 Number Present: 55 Completed Date: 2/21/2024 Age: From 0 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: 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, printed, and signed by Dawn McCrary, Child Care Consultant, and Joyce McAbee, Assistant Administrator, during the visit. Upon arrival, I made my presence known to Joyce McAbee, Assistant Administrator, Ms. McAbee was 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 children were observed having free choice play in the classrooms. All interactions were positive and nurturing. Supervision was adequate. There are three (3) 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. 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 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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. .0604(u);.0302(d)(8) 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. 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 and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. One staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment. Plan to have a current medical statement on file for the staff, per the staff and training worksheet, within 2 weeks. Plan to have newly hired staff’s current medical statement on file prior to employment. #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 Required for: All staff, including the director and individuals who volunteer more than once per week. Item requirement: 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: Due or before first day of work. One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work. Plan to have a TB test or screening, for the staff per the staff and training worksheet, on file within two weeks. Plan to have all newly hired staff’s current TB test on file on or before first day of work. 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). A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23. Plan to schedule, on a calendar, lockdown or shelter-in-place drills every three months. 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 3/6/24. 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: Environmental Rating Scale Assessment: Mt. Pisgah Lutheran Preschool is in cohort 1. Your preparation year is July 2023 to June 2024. Your assessment year will be July 2024 to June 2025. Please contact the Child and Family Resource Center to provide technical assistance during the prep year if desired. We discussed the importance of having each staff member’s most recent WORKS education letter on file. You stated that you plan to apply for the ERS assessment later this year. We discussed the difficulties your staff are experiencing with the WORKS system. 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 .0604 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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 .0102 · Violation

Name of Operation: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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: MT. PISGAH LUTHERAN PRESCHOOL Facility ID: 45000235 Consultant: DAWN MCCRARY Operation Type: Center Case Number: Visit Date: 7/20/2023 Number Present: 41 Completed Date: 7/20/2023 Age: From 0 To 5 Total Minutes: 335 Time In: 09:25 AM Time Out: 03:00 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 Katherine Montgomery, Administrator, during the visit. An electronic signed copy of the visit summary was electronically emailed to you. Today, I made my presence known to Ms. Montgomery and Joyce McAbee, Lead Teacher. Ms. Montgomery and Ms. McAbee 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-one (91) percentage as of 7/19/2023 Permit type – Four Star Child Care License, issued 1/31/20, earning four points for staff education, six points for program standards and one quality point. Special Services/Restrictions – Daytime care only; Meets Enhanced Space; Meets enhanced ratios. The last annual compliance visit was conducted on 8/2/22 The last fire drill was practiced on 7/20/23 The last lockdown drill was practiced on 5/22/23 The last playground inspection was documented on 6/23/23 The last fire inspection was approved on 8/17/22 The last sanitation inspection was conducted on 5/25/23 with twelve (12) demerits for Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness Plan was current The approved curriculum for four-year-old children is Creative Curriculum Upon my arrival, a fire drill was being practiced. During the walk-through monitoring, the children in space #1 were observed participating in free choice play in the classroom. The children in space #2 were observed having routine care, and free choice play in the classroom. The children in space #3 were transitioning from the playground to indoors, having routine care and washing hands. The children in space #4 were observed sleeping and moving about on the carpeted area. The children in space #5 were observed having free choice play on the playground. The children in space #9 were observed having free choice play in the classroom and transitioning to group, circle time. Spaces #6 and #7/8 were not in use during the visit. 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. Fifty-one (51) children are enrolled. Six (6) children’s files were monitored for child care requirements. Two (2) emergency medications were on-site and monitored for child care requirements. There is one (1) newly hired staff. The newly hired staff file and one (1) existing staff file was monitored for child care requirements. The staff and training worksheet was available and monitored during today’s 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/ The following violations were documented during today’s visit Violation Number Comment Rule 815 Electrical cords were accessible to infants and toddlers. Electrical cords were accessible to children in spaces #2 and #5. The cords were taped to the wall to make them inaccessible during the visit. 10A NCAC 09 .0604(f) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. Plastic wipe packages were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. .0604(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. A lockdown drill was practiced 5/22/23, the drill record was not complete. The information missing was added during the visit. .0604(u);.0302(d)(8) Technical Assistance provided 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. Easily torn plastics were accessible in spaces #2 and #5. The plastics were moved above five (5) feet during the visit for correction. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (f) Electrical cords shall not be accessible to infants and toddlers. Extension cords, except as approved by the local fire inspector, shall not be used. Frayed or cracked electrical cords shall be replaced. 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). Consultation For information concerning the extension grant, contact Kaitlyn Marshall, Child Care Consultant at kaitlyn.marshall@dhhs.nc.gov 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