ST. Stephen'S Lutheran Preschool

G.S. 110-90 · Violation

Name of Operation: ST. STEPHEN'S LUTHERAN PRESCHOOL Facility ID: 18000037 Consultant: MERIA WILDER Operation Type: Center Case Number: Visit Date: 4/14/2026 Number Present: 50 Completed Date: 4/14/2026 Age: From 3 To 5 Total Minutes: 225 Time In: 10:15 AM Time Out: 02:00 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Angela Parlier, Director, assisted me with today’s visit. Your last annual compliance visit was conducted on July 29, 2025. Your program currently operates with a Notice of Compliance, issued on March 12, 2024. I reviewed with you today the facility information found in our system. You stated there have been no changes to your phone number, mailing address, or corporate contact for the facility. You stated the email address had not changed. I reviewed the facility’s Notice of Compliance with you today. You stated there has been no change with the owner of your facility, St. Stephens Lutheran Church-Missouri Synod of Hick. Prior to today’s visit, your facility was listed as current-active in the NC Secretary of State. I reviewed the restrictions, capacity, and age range of your Notice of Compliance and observed these being maintained. Your center's compliance history was 100% prior to today’s visit. Your most recent fire inspection was dated May 23, 2025. Your most recent sanitation inspection was dated September 20, 2025, with a Superior classification and four (4) demerits. I completed a walk-through of the licensed indoor and outdoor spaces. Children were playing in activity areas, participating in teacher-directed whole group and small group activities, participating in routine care activities, and eating lunch. A current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. I monitored supervision, staff-child ratios, group sizes, approved space use, space capacities, and permit restrictions. I monitored for hazardous product storage, medication storage, medication administration, general safety, and discipline. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I monitored staff record files for one (1) returning staff member and three (3) new staff members hired since the last routine unannounced visit. I monitored a sampling of five (5) children’s record during today’s visit. I monitored health and safety requirements. The “Annual Compliance Monitoring Checklist for Child Care Centers” form was completed today. The following cited during today’s visit: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. The stationary structure on the playground has a regular slide and a tunnel slide that has cracks in the plastic. Also, there are areas on the metal part of the structure that have rust. G.S. 110-91(6); .0601(b) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member with a hire date of 10/15/25, did not have documentation of completing First Aid training within 90 days of being hired. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member with a hire date of 10/15/25, did not have documentation of completing CPR training within 90 days of being hired. .1102(d) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. A staff member with a hire date of 8/20/25 was not added to the ABCMS roster within 5 days of employment. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. There has not been an emergency drill completed since 9/17/25 and have not been completed quarterly. .0604(u);.0302(d)(8) • A staff member with a hire date of 8/20/25 was not added to the ABCMS roster within 5 days of employment. I suggest that the ABCMS roster for this facility be monitored quarterly to ensure that all staff members have been completed within the specified timeframe to prevent violations of child care requirements. • The stationary structure on the playground has a regular slide and a tunnel slide that has cracks in the plastic. Also, there are areas on the metal part of the structure that have rust. As discussed, a safe indoor and outdoor environment shall be provided for the children in care including providing equipment and furnishings that are in good repair, sturdy, stable, and free of hazards. To maintain this child care requirement in your outdoor play areas, I suggest that a walkthrough of the outdoor environment be conducted routinely and work orders for repairs sited be completed whenever hazards are identified. • One (1) staff member with a hire date of 10/15/25, did not have documentation of completing First Aid training within 90 days of being hired. I suggest that staff files be reviewed to ensure that all staff files are incompliance with staff training/documentation of training requirements. • One (1) staff member with a hire date of 10/15/25, did not have documentation of completing CPR training within 90 days of being hired. I suggest that staff files be reviewed to ensure that all staff files are incompliance with staff training/documentation of training requirements. • There has not been an emergency drill completed since 9/17/25 and have not been completed quarterly. I suggest that a calendar reminder be place on a calendar to ensure that all emergency drills are completed quarterly as required by child care rule. CONSULTATION: QRIS Information: Previously when contacted regarding QRIS, you stated that there has been no change in the decision previously made regarding remaining a Notice of compliance facility. However I did still provide you with the three QRIS Pathways to the Stars effective July 1, 2025. We discussed staff education (including ensuring all staff have WORKS accounts, understanding the 50% requirement for lead teachers and for other educators, and how work experience may count), enhanced ratios and space expectations, the Family and Community Engagement Foundational Practices, and Continuous Quality Improvement (CQI) Plans. Please visit the following link: https://ncchildcare.ncdhhs.gov/Provider/Licensing/StarRated-License/QRIS-Modernization. You will find more information and details about the three different pathways so that your program can begin working towards the star rated license. The following steps are how you can begin preparing for the Rated License process: Next Steps by Pathway If you choose Pathway 1: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Complete the “Environmental Rating Scale (ERS) Assessment Request” form electronically and submit to your child care consultant. • Confirm all staff have active WORKS accounts. • Complete the QRIS Staff Information and Education Worksheet electronically. • Begin planning for your three-month self-study using the applicable ITERS-3, ECERS-3, SACERS-U, OR FCCERS-3 books. • Prepare for Environmental Rating Scale (ERS) assessments. • Access resources, training, and outreach via ncrlap.org. • Work with CCR&R or Smart Start for support in preparation. • Identify CQI goals and begin planning for implementation. • Develop strategies for Family and Community Engagement. • If four-year-olds are enrolled, select and implement an approved curriculum. If you choose Pathway 2: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Confirm all staff have active WORKS accounts. • Complete the QRIS Staff Information and Education Worksheet electronically. • Identify CQI goals and begin planning for implementation. • Develop strategies for Family and Community Engagement. • Select and implement a curriculum. (4- and 5-star centers must use an approved curriculum and formative assessment tool for all ages.) • Arranging coaching or training options for administrators and lead teachers. If you choose Pathway 3: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Ensure all staff have active WORKS accounts. • If you are accredited through NAFCC, NECPA, AMS, or IMC, you may earn a three-star rated license with NO Education standards evaluation. • If you are accredited through NAFCC, NECPA, AMS, or IMC and would like to earn a four or five star rated license, the Education standard evaluation will determine the star rating earned. • If you are accredited through NAEYC, NAC, COGNIA, or your facility is Head Start and/or Early Head Start Education, NO Education standards evaluation is needed. • Documentation of accreditation status and Head Start designation must be submitted to process your star rated license. Today, you stated that your facility plans to remain a Notice of Compliance facility and does not wish to participate in the QRIS Pathway to the Stars at this time. • DCDEE Resources - Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/. - Child Care Rules and Laws: https://ncchildcare.ncdhhs.gov/Services/Licensing/Getting-a-License - Training and Professional Development: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development - Required Health and Safety Training: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings - Care for Children Receiving Subsidy: https://ncchildcare.ncdhhs.gov/Provider/Providing-Child-Care/Subsidized-Child-Care/Care-for-Children-Receiving-Subsidy - DCDEE Updates, Current Projects, and information applicable to Child Care in NC: https://ncchildcare.ncdhhs.gov/Whats-New • ABCMS SYSTEM: The process of notifying the Division of any new child care providers working who are hired or moved into the child care facility within five business days has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement as stated in G.S. 110-90.2 & .2703(r) to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. • Fire inspections are to be sent to the consultant within 7 business days of the inspection being completed. If the fire inspection report is not sent to the consultant within 7 business days a violation will be cited at the next monitoring visit • Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. • Be sure to contact the local fire department to schedule your next fire inspection. Your last fire inspection was conducted on May 23, 2025. COMPLIANCE PLAN: All violations cited and not corrected today must be corrected immediately. Please submit a written, signed, and dated statement to me at the email/address below detailing the steps taken to correct each violation. • Your compliance letter must include the following: 1. The name of your center 2. The center’s ID number 3. The date you write the letter 4. Address each violation stating how you corrected the violation and are now in compliance. 5. Your signature • Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters and acknowledgement statements. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I must receive your compliance letter no later than April 28, 2026. Please be aware any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. For your convenience, your compliance letter may be sent by email to: meria.wilder@dhhs.nc.gov When emailing the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. If you have any questions, feel free to contact me by phone at (980) 434-3877 or by email at meria.wilder@dhhs.nc.gov or my supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. Thank you for your time and assistance today. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110-91 · Violation

Name of Operation: ST. STEPHEN'S LUTHERAN PRESCHOOL Facility ID: 18000037 Consultant: MERIA WILDER Operation Type: Center Case Number: Visit Date: 4/14/2026 Number Present: 50 Completed Date: 4/14/2026 Age: From 3 To 5 Total Minutes: 225 Time In: 10:15 AM Time Out: 02:00 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 your program for compliance with applicable child care requirements for an annual compliance visit. You, Angela Parlier, Director, assisted me with today’s visit. Your last annual compliance visit was conducted on July 29, 2025. Your program currently operates with a Notice of Compliance, issued on March 12, 2024. I reviewed with you today the facility information found in our system. You stated there have been no changes to your phone number, mailing address, or corporate contact for the facility. You stated the email address had not changed. I reviewed the facility’s Notice of Compliance with you today. You stated there has been no change with the owner of your facility, St. Stephens Lutheran Church-Missouri Synod of Hick. Prior to today’s visit, your facility was listed as current-active in the NC Secretary of State. I reviewed the restrictions, capacity, and age range of your Notice of Compliance and observed these being maintained. Your center's compliance history was 100% prior to today’s visit. Your most recent fire inspection was dated May 23, 2025. Your most recent sanitation inspection was dated September 20, 2025, with a Superior classification and four (4) demerits. I completed a walk-through of the licensed indoor and outdoor spaces. Children were playing in activity areas, participating in teacher-directed whole group and small group activities, participating in routine care activities, and eating lunch. A current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. I monitored supervision, staff-child ratios, group sizes, approved space use, space capacities, and permit restrictions. I monitored for hazardous product storage, medication storage, medication administration, general safety, and discipline. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I monitored staff record files for one (1) returning staff member and three (3) new staff members hired since the last routine unannounced visit. I monitored a sampling of five (5) children’s record during today’s visit. I monitored health and safety requirements. The “Annual Compliance Monitoring Checklist for Child Care Centers” form was completed today. The following cited during today’s visit: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. The stationary structure on the playground has a regular slide and a tunnel slide that has cracks in the plastic. Also, there are areas on the metal part of the structure that have rust. G.S. 110-91(6); .0601(b) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member with a hire date of 10/15/25, did not have documentation of completing First Aid training within 90 days of being hired. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member with a hire date of 10/15/25, did not have documentation of completing CPR training within 90 days of being hired. .1102(d) 1805 A child care operator did not notify the Division of any new child care providers, as defined in G.S. 110-90.2(a)(2), who were hired or moved into the child care facility within five business days. A staff member with a hire date of 8/20/25 was not added to the ABCMS roster within 5 days of employment. G.S. 110-90.2 & .2703(r) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. There has not been an emergency drill completed since 9/17/25 and have not been completed quarterly. .0604(u);.0302(d)(8) • A staff member with a hire date of 8/20/25 was not added to the ABCMS roster within 5 days of employment. I suggest that the ABCMS roster for this facility be monitored quarterly to ensure that all staff members have been completed within the specified timeframe to prevent violations of child care requirements. • The stationary structure on the playground has a regular slide and a tunnel slide that has cracks in the plastic. Also, there are areas on the metal part of the structure that have rust. As discussed, a safe indoor and outdoor environment shall be provided for the children in care including providing equipment and furnishings that are in good repair, sturdy, stable, and free of hazards. To maintain this child care requirement in your outdoor play areas, I suggest that a walkthrough of the outdoor environment be conducted routinely and work orders for repairs sited be completed whenever hazards are identified. • One (1) staff member with a hire date of 10/15/25, did not have documentation of completing First Aid training within 90 days of being hired. I suggest that staff files be reviewed to ensure that all staff files are incompliance with staff training/documentation of training requirements. • One (1) staff member with a hire date of 10/15/25, did not have documentation of completing CPR training within 90 days of being hired. I suggest that staff files be reviewed to ensure that all staff files are incompliance with staff training/documentation of training requirements. • There has not been an emergency drill completed since 9/17/25 and have not been completed quarterly. I suggest that a calendar reminder be place on a calendar to ensure that all emergency drills are completed quarterly as required by child care rule. CONSULTATION: QRIS Information: Previously when contacted regarding QRIS, you stated that there has been no change in the decision previously made regarding remaining a Notice of compliance facility. However I did still provide you with the three QRIS Pathways to the Stars effective July 1, 2025. We discussed staff education (including ensuring all staff have WORKS accounts, understanding the 50% requirement for lead teachers and for other educators, and how work experience may count), enhanced ratios and space expectations, the Family and Community Engagement Foundational Practices, and Continuous Quality Improvement (CQI) Plans. Please visit the following link: https://ncchildcare.ncdhhs.gov/Provider/Licensing/StarRated-License/QRIS-Modernization. You will find more information and details about the three different pathways so that your program can begin working towards the star rated license. The following steps are how you can begin preparing for the Rated License process: Next Steps by Pathway If you choose Pathway 1: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Complete the “Environmental Rating Scale (ERS) Assessment Request” form electronically and submit to your child care consultant. • Confirm all staff have active WORKS accounts. • Complete the QRIS Staff Information and Education Worksheet electronically. • Begin planning for your three-month self-study using the applicable ITERS-3, ECERS-3, SACERS-U, OR FCCERS-3 books. • Prepare for Environmental Rating Scale (ERS) assessments. • Access resources, training, and outreach via ncrlap.org. • Work with CCR&R or Smart Start for support in preparation. • Identify CQI goals and begin planning for implementation. • Develop strategies for Family and Community Engagement. • If four-year-olds are enrolled, select and implement an approved curriculum. If you choose Pathway 2: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Confirm all staff have active WORKS accounts. • Complete the QRIS Staff Information and Education Worksheet electronically. • Identify CQI goals and begin planning for implementation. • Develop strategies for Family and Community Engagement. • Select and implement a curriculum. (4- and 5-star centers must use an approved curriculum and formative assessment tool for all ages.) • Arranging coaching or training options for administrators and lead teachers. If you choose Pathway 3: • Complete the “Application for Assessment for a Rated License for Centers” electronically and submit to your child care consultant. • Ensure all staff have active WORKS accounts. • If you are accredited through NAFCC, NECPA, AMS, or IMC, you may earn a three-star rated license with NO Education standards evaluation. • If you are accredited through NAFCC, NECPA, AMS, or IMC and would like to earn a four or five star rated license, the Education standard evaluation will determine the star rating earned. • If you are accredited through NAEYC, NAC, COGNIA, or your facility is Head Start and/or Early Head Start Education, NO Education standards evaluation is needed. • Documentation of accreditation status and Head Start designation must be submitted to process your star rated license. Today, you stated that your facility plans to remain a Notice of Compliance facility and does not wish to participate in the QRIS Pathway to the Stars at this time. • DCDEE Resources - Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/. - Child Care Rules and Laws: https://ncchildcare.ncdhhs.gov/Services/Licensing/Getting-a-License - Training and Professional Development: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development - Required Health and Safety Training: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings - Care for Children Receiving Subsidy: https://ncchildcare.ncdhhs.gov/Provider/Providing-Child-Care/Subsidized-Child-Care/Care-for-Children-Receiving-Subsidy - DCDEE Updates, Current Projects, and information applicable to Child Care in NC: https://ncchildcare.ncdhhs.gov/Whats-New • ABCMS SYSTEM: The process of notifying the Division of any new child care providers working who are hired or moved into the child care facility within five business days has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement as stated in G.S. 110-90.2 & .2703(r) to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-6401 and someone will assist you. • Fire inspections are to be sent to the consultant within 7 business days of the inspection being completed. If the fire inspection report is not sent to the consultant within 7 business days a violation will be cited at the next monitoring visit • Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. • Be sure to contact the local fire department to schedule your next fire inspection. Your last fire inspection was conducted on May 23, 2025. COMPLIANCE PLAN: All violations cited and not corrected today must be corrected immediately. Please submit a written, signed, and dated statement to me at the email/address below detailing the steps taken to correct each violation. • Your compliance letter must include the following: 1. The name of your center 2. The center’s ID number 3. The date you write the letter 4. Address each violation stating how you corrected the violation and are now in compliance. 5. Your signature • Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters and acknowledgement statements. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I must receive your compliance letter no later than April 28, 2026. Please be aware any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. For your convenience, your compliance letter may be sent by email to: meria.wilder@dhhs.nc.gov When emailing the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. If you have any questions, feel free to contact me by phone at (980) 434-3877 or by email at meria.wilder@dhhs.nc.gov or my supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. Thank you for your time and assistance today. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 . 1102 · Violation

Name of Operation: ST. STEPHEN'S LUTHERAN PRESCHOOL Facility ID: 18000037 Consultant: KIMBERLY CRANE Operation Type: Center Case Number: Visit Date: 1/30/2024 Number Present: 43 Completed Date: 1/30/2024 Age: From 3 To 5 Total Minutes: 274 Time In: 09:11 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for a routine unannounced visit. You, Angela Parlier, Director, assisted me with today’s visit. Your program currently operates with a five-star license, issued August 10, 2021, earning five points in staff education, seven points in program standards (meeting enhanced ratios and space), and one quality point for 75% of teachers having an AAS or higher in ECE/CD. Your center's compliance history was 90% as of January 16, 2024 and was reviewed with you today. Your facility, owned by St. Stephens Lutheran Church-Missouri Synod of Hickory, North Carolina, Inc., was reviewed on the North Carolina Secretary of State (NC SOS) website on January 16, 2024 and was observed listed as current- active. Your most recent fire inspection was dated May 16, 2023. Your most recent sanitation inspection was dated November 14, 2023 with a Superior classification and 0 demerits. You and I completed a walk-through of the facility today. I monitored all indoor areas. I observed children throughout the facility participating in free play in activity areas, eating snack, participating in a teacher-directed whole group activity, and eating lunch. I observed the teachers interacting and meeting the developmental needs for each of the children. I observed a current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. I observed the current menu posted on a parent information board at the facility entrance door outside the office area and in the kitchen. I observed meals prepared in the kitchen and served in the cafeteria. I observed lunch included a hotdog with chili on a bun, potato salad, baked beans, fruit cocktail, and unflavored milk. I observed and cited no violations related to nutritional requirements or food preparation. I observed cold food stored in a commercial refrigerator in the kitchen at a temperature of 36 degrees Fahrenheit and milk stored in a milk cooler in the cafeteria at a temperature of 36 degrees Fahrenheit. I observed and cited no violations related to food storage. I monitored hazardous product storage. I observed and cited no violations. I monitored medication storage and medication administration. I observed and cited one violation. I monitored general safety. I observed and cited no violations. I monitored discipline. I observed and cited no violation. I observed your facility using Opening the World of Learning™ (OWL) as the approved curriculum for a 5-Star facility serving children who are four and five years of age. I observed and cited no violation. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, outdoor safety inspections, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I observed and cited no violations. I reviewed staff record files for seven returning staff members to verify current and valid Criminal Background Check qualification letters, valid CPR and First Aid training, and completion of the Recognizing and Responding to Suspicions of Child Maltreatment training. I reviewed staff record files for two new staff members hired since the last annual compliance visit on June 26, 2023. I observed and cited two violations. I reviewed your written operational, administrative, and personnel policies and your parent participation plan at a routine unannounced visit on January 31, 2023. You stated your written administrative and personnel policies were included in the employee policies for the school and had not changed. You stated your written operational policies and parent participation policy were included in the parent handbook dated Fall 2023 – 2024. I monitored your updated written operational and parent participation policies. I observed and cited no violations. I observed children adequately supervised, highest voluntary enhanced staff-child ratios maintained, adequate approved voluntary enhanced space used, enhanced space capacities maintained, and permit restrictions including “Daytime care only”, “Reduced ratios by one (1) child per group at the 7-point level”, “Meets enhanced ratios”, and “Meets enhanced space” maintained during today’s visit. On September 18, 2023, I received an email from you stating that Ross Chiles, School Principal and Corporate Representative, was interested in a change of operation for the facility which would move the facility from a 5-Star Center to a Religious Sponsored Facility. On September 22, 2023, I responded with instructions to move forward in this change of operation explaining that you would need to submit your request in writing on school letterhead and submit written proof that your facility is sponsored by a church or synagogue or that they have a school of religious charter. On September 28, 2023, I received your Application – Facility Profile and Appendix F. On October 4, 2023, I received your formal request in writing. From September 28, 2023 to October 30, 2023, you submitted several church documents but none of them provided written proof of a church or synagogue sponsorship. Today, I observed your facility met the education and program requirements for a 5-Star center and for a religious sponsored facility. Today, I spoke with the senior pastor, assistant pastor, school principal, to request the written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter. The assistant pastor was able to show me documents from the North Carolina Secretary of State and the Federal Internal Revenue Service that verified the church was owned by a non-profit corporation. The assistant pastor was able to show me the constitution of the church which was approved by the Lutheran Church-Missouri Synod, a roster of churches included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran Church-Missouri Synod of Hickory, North Carolina, a roster of schools included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran School. The assistant pastor shared the 2001 Articles of Incorporation of St. Stephens Lutheran Church document with me. The senior pastor stated he had received a letter from the Lutheran Church-Missouri Synod when the church constitution was updated and approved by the Lutheran Church-Missouri Synod in 2011. The senior pastor stated he would locate that document and give to you. Today, I spoke with the senior pastor to request the completed Criminal Background Check (CBC) qualification letter from DCDEE. You stated you had given the senior pastor all the required information to submit an application to the ABCMS portal. The senior pastor stated he had received the information but had not completed the application or the fingerprinting. When you receive the letter as written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter and the CBC qualification letter for the senior pastor, you may submit those documents to me and I will process the change of operation request on your behalf. The following violations were observed and cited during today’s visit: Violation Number Comment Rule 847 Parent's medication authorization did not include required information. No permission to administer medication form and log were on file for one emergency prescription medication. 10A NCAC 09 .0803(4)(6-9) 1041 Prior to employment a Criminal Background Check was not completed. One new employee with a date of employment of 08/30/2023 completed new staff orientation training from 08/11/2023 through 08/25/2023 and their Criminal Background Check (CBC) qualification letter was dated 08/29/2023. G.S. 110-90.2(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Recognizing and Responding to Suspicions of Child Maltreatment training for one new employee with a date of employment of 08/30/2023 was due by 11/30/2023. The employee completed the Recognizing and Responding to Suspicions of Child Maltreatment training on 01/01/2024. The training was completed prior to this visit. .1102(g) TECHNICAL ASSISTANCE: 1. The Medication Permission to Administer form and log should be used to give permission to administer any prescription medication or oral non-prescription medication even if the medication information is included on a medical action plan. To maintain compliance with this child requirement, I suggested you include the Medication Permission to Administer form and log along with the medical action plan in your enrollment packet when a parent informs you that their child has a chronic illness and/or will need medication administered during the school day. 2. Employee’s may not complete any training prior to your receiving a CBC qualification letter. Completing training shows an intent to hire and an employee cannot be hired prior to verifying the employee’s qualification as a child care provider. To maintain compliance with this child requirement, I suggested you give all applicants the information to complete an application through the ABCMS portal, the Staff Health/Medical Assessment form, the TB screening form, and the TB test results form after the first interview and require all these documents be returned to you at the same time before offering the applicant a position and/or beginning the new staff orientation training process. 3. Per child care rule 10A NCAC 09 . 1102(g), each child care administrator and all staff should complete the Recognizing and Responding to Suspicions of Child Maltreatment training through the NC Prevent Child Abuse website and/or present the administrator with the completion certificate within the first ninety days of employment. To maintain compliance with this child care requirement, I suggested you require the Recognizing and Responding to Suspicions of Child Maltreatment training be completed within the first six weeks of employment. CONSULTATION: 1. Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. 2. Visit NC Child Care Health and Safety Resource Center at http://healthychildcare.unc.edu to find the following resources: technical assistance, coaching support, resources, handwashing and diapering posters, monthly newsletters, and a list of approved in-service trainings including, but not limited to, ITS-SIDS training and Emergency Preparedness and Response in Child Care training. 3. The Change of Information form for CBC is listed in law. When a new staff member starts working at a facility and gives the administrator a CBC qualification letter that was previously completed while working at another facility, but is still current, the administrator must send a Change of Information form for that new staff member to the CBC unit. The Change of Information form can be found on DCDEE’s website under Provider Documents and Forms. 4. The Staff Health Assessment/Medical Report form should include the date of the assessment as the date the health exam was completed as well as the health care professional’s signature and date of signature. To maintain compliance with this child care requirement, I suggest you highlight the “date of the assessment” on the document so remind health care professionals that information is required in addition to their signature and date of signature. 5. During today’s visit, you asked if you were required to use the child enrollment application provided by DCDEE or if you could create your own application. I explained you may create your child enrollment application as long as it included all the information required by the child rules. You stated you had created a child enrollment application that included all the same information as the DCDEE form but changed the layout and font size to give more room to write and to eliminate applicants overlooking the health care needs section. I observed and approved the child enrollment application form you created. You stated you planned to begin using the new application form for enrollment in the spring of 2024. COMPLIANCE PLAN: No compliance documentation is needed for those violations corrected during today’s visit. In the visit summary prepared for you today, I documented the corrective actions taken to correct those violations. All violations cited and not corrected today must be corrected immediately. Please submit a written, signed, and dated statement to me at the email/address below detailing the steps taken to correct each violation. 1) Your compliance letter must include the following: 1. The name of your center 2. The center’s ID number 3. The date you write the letter 4. Address each violation stating how you corrected the violation and are now in compliance. 5. Address your plan to ensure that you will not have that violation again. 6. Your signature 2) Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters, acknowledgement statements, and photographs for me to use to verify compliance. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I should receive your compliance letter no later than February 13, 2024. Please be aware any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. If you cannot meet the requirements by this date you shall contact me with a timeline of the corrections. In some cases, this timeline may be extended. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Child care programs are required to maintain compliance with all applicable child care rules and regulations at all times. North Carolina General Statute 110-90(4)(d) requires all child care facilities to maintain a compliance history of at least seventy-five percent (75%) for the past eighteen (18) months or during the length of time the facility has operated, whichever is less. Failure to do so may result in the issuance of a provisional license or other administrative action against the facility's license. Any violations cited during a visit may affect your score. Your letter may be mailed to me at: Kimberly Crane Post Office Box 6217 Hickory, NC 28603 For your convenience, your compliance letter may be sent by email to: kimberly.crane@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included in the body of the email: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. We appreciate all you, your staff, and the church do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (828) 493-6390 or by email at kimberly.crane@dhhs.nc.gov or our lead consultant and interim licensing supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. Thank you for your time today. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0803 · Violation

Name of Operation: ST. STEPHEN'S LUTHERAN PRESCHOOL Facility ID: 18000037 Consultant: KIMBERLY CRANE Operation Type: Center Case Number: Visit Date: 1/30/2024 Number Present: 43 Completed Date: 1/30/2024 Age: From 3 To 5 Total Minutes: 274 Time In: 09:11 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for a routine unannounced visit. You, Angela Parlier, Director, assisted me with today’s visit. Your program currently operates with a five-star license, issued August 10, 2021, earning five points in staff education, seven points in program standards (meeting enhanced ratios and space), and one quality point for 75% of teachers having an AAS or higher in ECE/CD. Your center's compliance history was 90% as of January 16, 2024 and was reviewed with you today. Your facility, owned by St. Stephens Lutheran Church-Missouri Synod of Hickory, North Carolina, Inc., was reviewed on the North Carolina Secretary of State (NC SOS) website on January 16, 2024 and was observed listed as current- active. Your most recent fire inspection was dated May 16, 2023. Your most recent sanitation inspection was dated November 14, 2023 with a Superior classification and 0 demerits. You and I completed a walk-through of the facility today. I monitored all indoor areas. I observed children throughout the facility participating in free play in activity areas, eating snack, participating in a teacher-directed whole group activity, and eating lunch. I observed the teachers interacting and meeting the developmental needs for each of the children. I observed a current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. I observed the current menu posted on a parent information board at the facility entrance door outside the office area and in the kitchen. I observed meals prepared in the kitchen and served in the cafeteria. I observed lunch included a hotdog with chili on a bun, potato salad, baked beans, fruit cocktail, and unflavored milk. I observed and cited no violations related to nutritional requirements or food preparation. I observed cold food stored in a commercial refrigerator in the kitchen at a temperature of 36 degrees Fahrenheit and milk stored in a milk cooler in the cafeteria at a temperature of 36 degrees Fahrenheit. I observed and cited no violations related to food storage. I monitored hazardous product storage. I observed and cited no violations. I monitored medication storage and medication administration. I observed and cited one violation. I monitored general safety. I observed and cited no violations. I monitored discipline. I observed and cited no violation. I observed your facility using Opening the World of Learning™ (OWL) as the approved curriculum for a 5-Star facility serving children who are four and five years of age. I observed and cited no violation. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, outdoor safety inspections, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I observed and cited no violations. I reviewed staff record files for seven returning staff members to verify current and valid Criminal Background Check qualification letters, valid CPR and First Aid training, and completion of the Recognizing and Responding to Suspicions of Child Maltreatment training. I reviewed staff record files for two new staff members hired since the last annual compliance visit on June 26, 2023. I observed and cited two violations. I reviewed your written operational, administrative, and personnel policies and your parent participation plan at a routine unannounced visit on January 31, 2023. You stated your written administrative and personnel policies were included in the employee policies for the school and had not changed. You stated your written operational policies and parent participation policy were included in the parent handbook dated Fall 2023 – 2024. I monitored your updated written operational and parent participation policies. I observed and cited no violations. I observed children adequately supervised, highest voluntary enhanced staff-child ratios maintained, adequate approved voluntary enhanced space used, enhanced space capacities maintained, and permit restrictions including “Daytime care only”, “Reduced ratios by one (1) child per group at the 7-point level”, “Meets enhanced ratios”, and “Meets enhanced space” maintained during today’s visit. On September 18, 2023, I received an email from you stating that Ross Chiles, School Principal and Corporate Representative, was interested in a change of operation for the facility which would move the facility from a 5-Star Center to a Religious Sponsored Facility. On September 22, 2023, I responded with instructions to move forward in this change of operation explaining that you would need to submit your request in writing on school letterhead and submit written proof that your facility is sponsored by a church or synagogue or that they have a school of religious charter. On September 28, 2023, I received your Application – Facility Profile and Appendix F. On October 4, 2023, I received your formal request in writing. From September 28, 2023 to October 30, 2023, you submitted several church documents but none of them provided written proof of a church or synagogue sponsorship. Today, I observed your facility met the education and program requirements for a 5-Star center and for a religious sponsored facility. Today, I spoke with the senior pastor, assistant pastor, school principal, to request the written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter. The assistant pastor was able to show me documents from the North Carolina Secretary of State and the Federal Internal Revenue Service that verified the church was owned by a non-profit corporation. The assistant pastor was able to show me the constitution of the church which was approved by the Lutheran Church-Missouri Synod, a roster of churches included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran Church-Missouri Synod of Hickory, North Carolina, a roster of schools included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran School. The assistant pastor shared the 2001 Articles of Incorporation of St. Stephens Lutheran Church document with me. The senior pastor stated he had received a letter from the Lutheran Church-Missouri Synod when the church constitution was updated and approved by the Lutheran Church-Missouri Synod in 2011. The senior pastor stated he would locate that document and give to you. Today, I spoke with the senior pastor to request the completed Criminal Background Check (CBC) qualification letter from DCDEE. You stated you had given the senior pastor all the required information to submit an application to the ABCMS portal. The senior pastor stated he had received the information but had not completed the application or the fingerprinting. When you receive the letter as written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter and the CBC qualification letter for the senior pastor, you may submit those documents to me and I will process the change of operation request on your behalf. The following violations were observed and cited during today’s visit: Violation Number Comment Rule 847 Parent's medication authorization did not include required information. No permission to administer medication form and log were on file for one emergency prescription medication. 10A NCAC 09 .0803(4)(6-9) 1041 Prior to employment a Criminal Background Check was not completed. One new employee with a date of employment of 08/30/2023 completed new staff orientation training from 08/11/2023 through 08/25/2023 and their Criminal Background Check (CBC) qualification letter was dated 08/29/2023. G.S. 110-90.2(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Recognizing and Responding to Suspicions of Child Maltreatment training for one new employee with a date of employment of 08/30/2023 was due by 11/30/2023. The employee completed the Recognizing and Responding to Suspicions of Child Maltreatment training on 01/01/2024. The training was completed prior to this visit. .1102(g) TECHNICAL ASSISTANCE: 1. The Medication Permission to Administer form and log should be used to give permission to administer any prescription medication or oral non-prescription medication even if the medication information is included on a medical action plan. To maintain compliance with this child requirement, I suggested you include the Medication Permission to Administer form and log along with the medical action plan in your enrollment packet when a parent informs you that their child has a chronic illness and/or will need medication administered during the school day. 2. Employee’s may not complete any training prior to your receiving a CBC qualification letter. Completing training shows an intent to hire and an employee cannot be hired prior to verifying the employee’s qualification as a child care provider. To maintain compliance with this child requirement, I suggested you give all applicants the information to complete an application through the ABCMS portal, the Staff Health/Medical Assessment form, the TB screening form, and the TB test results form after the first interview and require all these documents be returned to you at the same time before offering the applicant a position and/or beginning the new staff orientation training process. 3. Per child care rule 10A NCAC 09 . 1102(g), each child care administrator and all staff should complete the Recognizing and Responding to Suspicions of Child Maltreatment training through the NC Prevent Child Abuse website and/or present the administrator with the completion certificate within the first ninety days of employment. To maintain compliance with this child care requirement, I suggested you require the Recognizing and Responding to Suspicions of Child Maltreatment training be completed within the first six weeks of employment. CONSULTATION: 1. Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. 2. Visit NC Child Care Health and Safety Resource Center at http://healthychildcare.unc.edu to find the following resources: technical assistance, coaching support, resources, handwashing and diapering posters, monthly newsletters, and a list of approved in-service trainings including, but not limited to, ITS-SIDS training and Emergency Preparedness and Response in Child Care training. 3. The Change of Information form for CBC is listed in law. When a new staff member starts working at a facility and gives the administrator a CBC qualification letter that was previously completed while working at another facility, but is still current, the administrator must send a Change of Information form for that new staff member to the CBC unit. The Change of Information form can be found on DCDEE’s website under Provider Documents and Forms. 4. The Staff Health Assessment/Medical Report form should include the date of the assessment as the date the health exam was completed as well as the health care professional’s signature and date of signature. To maintain compliance with this child care requirement, I suggest you highlight the “date of the assessment” on the document so remind health care professionals that information is required in addition to their signature and date of signature. 5. During today’s visit, you asked if you were required to use the child enrollment application provided by DCDEE or if you could create your own application. I explained you may create your child enrollment application as long as it included all the information required by the child rules. You stated you had created a child enrollment application that included all the same information as the DCDEE form but changed the layout and font size to give more room to write and to eliminate applicants overlooking the health care needs section. I observed and approved the child enrollment application form you created. You stated you planned to begin using the new application form for enrollment in the spring of 2024. COMPLIANCE PLAN: No compliance documentation is needed for those violations corrected during today’s visit. In the visit summary prepared for you today, I documented the corrective actions taken to correct those violations. All violations cited and not corrected today must be corrected immediately. Please submit a written, signed, and dated statement to me at the email/address below detailing the steps taken to correct each violation. 1) Your compliance letter must include the following: 1. The name of your center 2. The center’s ID number 3. The date you write the letter 4. Address each violation stating how you corrected the violation and are now in compliance. 5. Address your plan to ensure that you will not have that violation again. 6. Your signature 2) Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters, acknowledgement statements, and photographs for me to use to verify compliance. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I should receive your compliance letter no later than February 13, 2024. Please be aware any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. If you cannot meet the requirements by this date you shall contact me with a timeline of the corrections. In some cases, this timeline may be extended. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Child care programs are required to maintain compliance with all applicable child care rules and regulations at all times. North Carolina General Statute 110-90(4)(d) requires all child care facilities to maintain a compliance history of at least seventy-five percent (75%) for the past eighteen (18) months or during the length of time the facility has operated, whichever is less. Failure to do so may result in the issuance of a provisional license or other administrative action against the facility's license. Any violations cited during a visit may affect your score. Your letter may be mailed to me at: Kimberly Crane Post Office Box 6217 Hickory, NC 28603 For your convenience, your compliance letter may be sent by email to: kimberly.crane@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included in the body of the email: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. We appreciate all you, your staff, and the church do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (828) 493-6390 or by email at kimberly.crane@dhhs.nc.gov or our lead consultant and interim licensing supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. Thank you for your time today. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110-90 · Violation

Name of Operation: ST. STEPHEN'S LUTHERAN PRESCHOOL Facility ID: 18000037 Consultant: KIMBERLY CRANE Operation Type: Center Case Number: Visit Date: 1/30/2024 Number Present: 43 Completed Date: 1/30/2024 Age: From 3 To 5 Total Minutes: 274 Time In: 09:11 AM Time Out: 01:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for a routine unannounced visit. You, Angela Parlier, Director, assisted me with today’s visit. Your program currently operates with a five-star license, issued August 10, 2021, earning five points in staff education, seven points in program standards (meeting enhanced ratios and space), and one quality point for 75% of teachers having an AAS or higher in ECE/CD. Your center's compliance history was 90% as of January 16, 2024 and was reviewed with you today. Your facility, owned by St. Stephens Lutheran Church-Missouri Synod of Hickory, North Carolina, Inc., was reviewed on the North Carolina Secretary of State (NC SOS) website on January 16, 2024 and was observed listed as current- active. Your most recent fire inspection was dated May 16, 2023. Your most recent sanitation inspection was dated November 14, 2023 with a Superior classification and 0 demerits. You and I completed a walk-through of the facility today. I monitored all indoor areas. I observed children throughout the facility participating in free play in activity areas, eating snack, participating in a teacher-directed whole group activity, and eating lunch. I observed the teachers interacting and meeting the developmental needs for each of the children. I observed a current menu documented appropriate nutritious snacks and meals, showed a variety of foods, and complied with Meal Patterns for Children in Child Care Programs. I observed the current menu posted on a parent information board at the facility entrance door outside the office area and in the kitchen. I observed meals prepared in the kitchen and served in the cafeteria. I observed lunch included a hotdog with chili on a bun, potato salad, baked beans, fruit cocktail, and unflavored milk. I observed and cited no violations related to nutritional requirements or food preparation. I observed cold food stored in a commercial refrigerator in the kitchen at a temperature of 36 degrees Fahrenheit and milk stored in a milk cooler in the cafeteria at a temperature of 36 degrees Fahrenheit. I observed and cited no violations related to food storage. I monitored hazardous product storage. I observed and cited no violations. I monitored medication storage and medication administration. I observed and cited one violation. I monitored general safety. I observed and cited no violations. I monitored discipline. I observed and cited no violation. I observed your facility using Opening the World of Learning™ (OWL) as the approved curriculum for a 5-Star facility serving children who are four and five years of age. I observed and cited no violation. I monitored program records including emergency medical care plan, safe arrival and departure procedures, incident log, outdoor safety inspections, fire drills, emergency drills, and your Emergency Preparedness Response (EPR) Plan. I observed and cited no violations. I reviewed staff record files for seven returning staff members to verify current and valid Criminal Background Check qualification letters, valid CPR and First Aid training, and completion of the Recognizing and Responding to Suspicions of Child Maltreatment training. I reviewed staff record files for two new staff members hired since the last annual compliance visit on June 26, 2023. I observed and cited two violations. I reviewed your written operational, administrative, and personnel policies and your parent participation plan at a routine unannounced visit on January 31, 2023. You stated your written administrative and personnel policies were included in the employee policies for the school and had not changed. You stated your written operational policies and parent participation policy were included in the parent handbook dated Fall 2023 – 2024. I monitored your updated written operational and parent participation policies. I observed and cited no violations. I observed children adequately supervised, highest voluntary enhanced staff-child ratios maintained, adequate approved voluntary enhanced space used, enhanced space capacities maintained, and permit restrictions including “Daytime care only”, “Reduced ratios by one (1) child per group at the 7-point level”, “Meets enhanced ratios”, and “Meets enhanced space” maintained during today’s visit. On September 18, 2023, I received an email from you stating that Ross Chiles, School Principal and Corporate Representative, was interested in a change of operation for the facility which would move the facility from a 5-Star Center to a Religious Sponsored Facility. On September 22, 2023, I responded with instructions to move forward in this change of operation explaining that you would need to submit your request in writing on school letterhead and submit written proof that your facility is sponsored by a church or synagogue or that they have a school of religious charter. On September 28, 2023, I received your Application – Facility Profile and Appendix F. On October 4, 2023, I received your formal request in writing. From September 28, 2023 to October 30, 2023, you submitted several church documents but none of them provided written proof of a church or synagogue sponsorship. Today, I observed your facility met the education and program requirements for a 5-Star center and for a religious sponsored facility. Today, I spoke with the senior pastor, assistant pastor, school principal, to request the written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter. The assistant pastor was able to show me documents from the North Carolina Secretary of State and the Federal Internal Revenue Service that verified the church was owned by a non-profit corporation. The assistant pastor was able to show me the constitution of the church which was approved by the Lutheran Church-Missouri Synod, a roster of churches included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran Church-Missouri Synod of Hickory, North Carolina, a roster of schools included in the Lutheran Church-Missouri Synod which included St. Stephen’s Lutheran School. The assistant pastor shared the 2001 Articles of Incorporation of St. Stephens Lutheran Church document with me. The senior pastor stated he had received a letter from the Lutheran Church-Missouri Synod when the church constitution was updated and approved by the Lutheran Church-Missouri Synod in 2011. The senior pastor stated he would locate that document and give to you. Today, I spoke with the senior pastor to request the completed Criminal Background Check (CBC) qualification letter from DCDEE. You stated you had given the senior pastor all the required information to submit an application to the ABCMS portal. The senior pastor stated he had received the information but had not completed the application or the fingerprinting. When you receive the letter as written proof that your facility is sponsored by a church or synagogue or that you have a school of a religious charter and the CBC qualification letter for the senior pastor, you may submit those documents to me and I will process the change of operation request on your behalf. The following violations were observed and cited during today’s visit: Violation Number Comment Rule 847 Parent's medication authorization did not include required information. No permission to administer medication form and log were on file for one emergency prescription medication. 10A NCAC 09 .0803(4)(6-9) 1041 Prior to employment a Criminal Background Check was not completed. One new employee with a date of employment of 08/30/2023 completed new staff orientation training from 08/11/2023 through 08/25/2023 and their Criminal Background Check (CBC) qualification letter was dated 08/29/2023. G.S. 110-90.2(b) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Recognizing and Responding to Suspicions of Child Maltreatment training for one new employee with a date of employment of 08/30/2023 was due by 11/30/2023. The employee completed the Recognizing and Responding to Suspicions of Child Maltreatment training on 01/01/2024. The training was completed prior to this visit. .1102(g) TECHNICAL ASSISTANCE: 1. The Medication Permission to Administer form and log should be used to give permission to administer any prescription medication or oral non-prescription medication even if the medication information is included on a medical action plan. To maintain compliance with this child requirement, I suggested you include the Medication Permission to Administer form and log along with the medical action plan in your enrollment packet when a parent informs you that their child has a chronic illness and/or will need medication administered during the school day. 2. Employee’s may not complete any training prior to your receiving a CBC qualification letter. Completing training shows an intent to hire and an employee cannot be hired prior to verifying the employee’s qualification as a child care provider. To maintain compliance with this child requirement, I suggested you give all applicants the information to complete an application through the ABCMS portal, the Staff Health/Medical Assessment form, the TB screening form, and the TB test results form after the first interview and require all these documents be returned to you at the same time before offering the applicant a position and/or beginning the new staff orientation training process. 3. Per child care rule 10A NCAC 09 . 1102(g), each child care administrator and all staff should complete the Recognizing and Responding to Suspicions of Child Maltreatment training through the NC Prevent Child Abuse website and/or present the administrator with the completion certificate within the first ninety days of employment. To maintain compliance with this child care requirement, I suggested you require the Recognizing and Responding to Suspicions of Child Maltreatment training be completed within the first six weeks of employment. CONSULTATION: 1. Please continue to visit DCDEE’s website at https://ncchildcare.ncdhhs.gov/ to get the latest information for child care settings and child care updates including the most up to date documents and forms. 2. Visit NC Child Care Health and Safety Resource Center at http://healthychildcare.unc.edu to find the following resources: technical assistance, coaching support, resources, handwashing and diapering posters, monthly newsletters, and a list of approved in-service trainings including, but not limited to, ITS-SIDS training and Emergency Preparedness and Response in Child Care training. 3. The Change of Information form for CBC is listed in law. When a new staff member starts working at a facility and gives the administrator a CBC qualification letter that was previously completed while working at another facility, but is still current, the administrator must send a Change of Information form for that new staff member to the CBC unit. The Change of Information form can be found on DCDEE’s website under Provider Documents and Forms. 4. The Staff Health Assessment/Medical Report form should include the date of the assessment as the date the health exam was completed as well as the health care professional’s signature and date of signature. To maintain compliance with this child care requirement, I suggest you highlight the “date of the assessment” on the document so remind health care professionals that information is required in addition to their signature and date of signature. 5. During today’s visit, you asked if you were required to use the child enrollment application provided by DCDEE or if you could create your own application. I explained you may create your child enrollment application as long as it included all the information required by the child rules. You stated you had created a child enrollment application that included all the same information as the DCDEE form but changed the layout and font size to give more room to write and to eliminate applicants overlooking the health care needs section. I observed and approved the child enrollment application form you created. You stated you planned to begin using the new application form for enrollment in the spring of 2024. COMPLIANCE PLAN: No compliance documentation is needed for those violations corrected during today’s visit. In the visit summary prepared for you today, I documented the corrective actions taken to correct those violations. All violations cited and not corrected today must be corrected immediately. Please submit a written, signed, and dated statement to me at the email/address below detailing the steps taken to correct each violation. 1) Your compliance letter must include the following: 1. The name of your center 2. The center’s ID number 3. The date you write the letter 4. Address each violation stating how you corrected the violation and are now in compliance. 5. Address your plan to ensure that you will not have that violation again. 6. Your signature 2) Supporting documentation including the following: Please send supporting documentation such as training certificates, CBC letters, acknowledgement statements, and photographs for me to use to verify compliance. Please DO NOT send staff or child medical documents or documentation for verification as this is a violation of HIPPA protocol. If needed I will verify these documents at the next monitoring visit. I should receive your compliance letter no later than February 13, 2024. Please be aware any information submitted by you is legal documentation. If you state in your compliance letter that corrections have been made when they have not, it will be considered falsification of information. If you cannot meet the requirements by this date you shall contact me with a timeline of the corrections. In some cases, this timeline may be extended. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development and Early Education may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Child care programs are required to maintain compliance with all applicable child care rules and regulations at all times. North Carolina General Statute 110-90(4)(d) requires all child care facilities to maintain a compliance history of at least seventy-five percent (75%) for the past eighteen (18) months or during the length of time the facility has operated, whichever is less. Failure to do so may result in the issuance of a provisional license or other administrative action against the facility's license. Any violations cited during a visit may affect your score. Your letter may be mailed to me at: Kimberly Crane Post Office Box 6217 Hickory, NC 28603 For your convenience, your compliance letter may be sent by email to: kimberly.crane@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included in the body of the email: name, position, facility name, and facility ID number. An example is: Jane Doe, Administrator AAA Child Care ID # 12345678 At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you today. We appreciate all you, your staff, and the church do to serve the children and families in your community. If you have any questions, feel free to contact me by phone at (828) 493-6390 or by email at kimberly.crane@dhhs.nc.gov or our lead consultant and interim licensing supervisor, Erin Pickard, by email at erin.pickard@dhhs.nc.gov. Thank you for your time today. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times